Provider Demographics
NPI:1821250960
Name:BEETHAM, PORSCHE D (DO)
Entity Type:Individual
Prefix:
First Name:PORSCHE
Middle Name:D
Last Name:BEETHAM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 SUMMIT AVE
Mailing Address - Street 2:MSO PHYSICIAN BILLING
Mailing Address - City:STEUBENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43952-2667
Mailing Address - Country:US
Mailing Address - Phone:740-283-7597
Mailing Address - Fax:740-283-7608
Practice Address - Street 1:82424 CADIZ JEWETT ROAD
Practice Address - Street 2:
Practice Address - City:CADIZ
Practice Address - State:OH
Practice Address - Zip Code:43907-9427
Practice Address - Country:US
Practice Address - Phone:740-320-4048
Practice Address - Fax:740-652-6457
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH34.009929207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0050014Medicaid
OH0050014Medicaid