Provider Demographics
NPI:1164482667
Name:BRECKENRIDGE, MARY BETH (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:BRECKENRIDGE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-293-2594
Mailing Address - Fax:614-293-4487
Practice Address - Street 1:1800 ZOLLINGER RD FL 2
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43221-2800
Practice Address - Country:US
Practice Address - Phone:614-293-7677
Practice Address - Fax:614-293-5614
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2020-12-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OH35065366207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0953982Medicaid
OHH011411Medicare PIN
OHBR075764Medicare PIN