Provider Demographics
NPI:1942400049
Name:BETHEL MEDICAL GROUP, P. C.
Entity Type:Organization
Organization Name:BETHEL MEDICAL GROUP, P. C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAPIRO
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:203-744-1639
Mailing Address - Street 1:155 GREENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:CT
Mailing Address - Zip Code:06801-2527
Mailing Address - Country:US
Mailing Address - Phone:203-744-1639
Mailing Address - Fax:203-748-1202
Practice Address - Street 1:155 GREENWOOD AVE
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:CT
Practice Address - Zip Code:06801-2527
Practice Address - Country:US
Practice Address - Phone:203-744-1639
Practice Address - Fax:203-748-1202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT016412207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C00925Medicare PIN