Provider Demographics
NPI:1487824983
Name:BETTS FAMILY MEDICAL CLINIC, LTD
Entity Type:Organization
Organization Name:BETTS FAMILY MEDICAL CLINIC, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:ROGER
Authorized Official - Last Name:BETTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:608-884-2544
Mailing Address - Street 1:528 STOUGHTON RD
Mailing Address - Street 2:
Mailing Address - City:EDGERTON
Mailing Address - State:WI
Mailing Address - Zip Code:53534-1137
Mailing Address - Country:US
Mailing Address - Phone:608-884-2544
Mailing Address - Fax:608-884-2912
Practice Address - Street 1:528 STOUGHTON RD
Practice Address - Street 2:
Practice Address - City:EDGERTON
Practice Address - State:WI
Practice Address - Zip Code:53534-1137
Practice Address - Country:US
Practice Address - Phone:608-884-2544
Practice Address - Fax:608-884-2912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39870020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32445200Medicaid