Provider Demographics
NPI:1467654616
Name:WHITESIDE, BETH ELLEN (MD)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:ELLEN
Last Name:WHITESIDE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 TROY SCHENECTADY RD
Mailing Address - Street 2:SUIRE 203
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2442
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:711 TROY SCHENECTADY RD
Practice Address - Street 2:SUITE 114
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-2442
Practice Address - Country:US
Practice Address - Phone:518-786-1600
Practice Address - Fax:518-786-1606
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007-008442085R0202X
NY2482042085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCFW0196180OtherDEA
NC2066891Medicare PIN
NCFW0196180OtherDEA