Provider Demographics
NPI:1619399805
Name:BETHEL PARK MEDICAL AND WELLNESS
Entity Type:Organization
Organization Name:BETHEL PARK MEDICAL AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEONARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-279-4522
Mailing Address - Street 1:2746 S PARK RD
Mailing Address - Street 2:
Mailing Address - City:BETHEL PARK
Mailing Address - State:PA
Mailing Address - Zip Code:15102-3806
Mailing Address - Country:US
Mailing Address - Phone:412-831-8000
Mailing Address - Fax:412-833-2536
Practice Address - Street 1:2746 S PARK RD
Practice Address - Street 2:
Practice Address - City:BETHEL PARK
Practice Address - State:PA
Practice Address - Zip Code:15102-3806
Practice Address - Country:US
Practice Address - Phone:412-831-8000
Practice Address - Fax:412-833-2536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-08
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD420553207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA=========OtherTAX ID