Provider Demographics
NPI:1225007388
Name:BETTERIDGE, BENJAMIN BRYCE (MD, CAQ SPORTS MEDIC)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:BRYCE
Last Name:BETTERIDGE
Suffix:
Gender:M
Credentials:MD, CAQ SPORTS MEDIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2721 SOUNDVIEW DR. WEST
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466
Mailing Address - Country:US
Mailing Address - Phone:253-283-9954
Mailing Address - Fax:
Practice Address - Street 1:3733 SO THOMPSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98418
Practice Address - Country:US
Practice Address - Phone:253-472-4473
Practice Address - Fax:253-474-3056
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2948311205204C00000X
WAMD00043643204C00000X, 207PS0010X
UT294831-1205207PS0010X
WA43643207PT0002X, 207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine
No204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
No207PT0002XAllopathic & Osteopathic PhysiciansEmergency MedicineMedical Toxicology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT942854058788-D6149Medicaid
005532646Medicare PIN
005761919Medicare PIN
UT942854058788-D6149Medicaid
UT000063166Medicare PIN