Provider Demographics
NPI:1255820841
Name:CANVER, BETHANY RENEE (MD)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:RENEE
Last Name:CANVER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 FEDERAL ST STE 200
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-1088
Mailing Address - Country:US
Mailing Address - Phone:848-288-6935
Mailing Address - Fax:732-790-0107
Practice Address - Street 1:390 N BROADWAY BLDG STE 100
Practice Address - Street 2:
Practice Address - City:PENNSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08070-1253
Practice Address - Country:US
Practice Address - Phone:856-678-6411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA11541400207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008056168Medicaid
CT008039745Medicaid
CT008068298Medicaid
CT008056033Medicaid
CT008103365Medicaid
CT004217099Medicaid