Provider Demographics
NPI:1154671642
Name:EDWARD D BETZ MD A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:EDWARD D BETZ MD A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:CYR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-957-2192
Mailing Address - Street 1:4555 SHERMAN OAKS AVE
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-3011
Mailing Address - Country:US
Mailing Address - Phone:818-981-5800
Mailing Address - Fax:818-981-2879
Practice Address - Street 1:4555 SHERMAN OAKS AVE
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-3011
Practice Address - Country:US
Practice Address - Phone:818-981-5800
Practice Address - Fax:818-981-2879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-12
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG34138207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG34138Medicare PIN