Provider Demographics
NPI:1164507117
Name:BETHESDA MEDICAL CENTER
Entity Type:Organization
Organization Name:BETHESDA MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:H
Authorized Official - Last Name:KWON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-300-0010
Mailing Address - Street 1:PO BOX 1557
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90637-1557
Mailing Address - Country:US
Mailing Address - Phone:213-300-0010
Mailing Address - Fax:714-484-9019
Practice Address - Street 1:137 S KNOTT AVE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-1406
Practice Address - Country:US
Practice Address - Phone:714-484-9000
Practice Address - Fax:714-484-9019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16134Medicare ID - Type UnspecifiedPROVIDER#