Provider Demographics
NPI:1508379322
Name:BETHEL UNIVERSTIY
Entity Type:Organization
Organization Name:BETHEL UNIVERSTIY
Other - Org Name:BETHEL SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:DUNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-352-6428
Mailing Address - Street 1:15305 DALLAS PKWY STE 800
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-6415
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:325 CHERRY AVE
Practice Address - Street 2:
Practice Address - City:MC KENZIE
Practice Address - State:TN
Practice Address - Zip Code:38201-1769
Practice Address - Country:US
Practice Address - Phone:972-367-4845
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-15
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN24365207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty