Provider Demographics
NPI:1770696361
Name:THOMPSON, BETHANIE (MD)
Entity type:Individual
Prefix:
First Name:BETHANIE
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BETHANIE
Other - Middle Name:
Other - Last Name:HARRIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:721 3 MILE RD NW STE 200
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49544-8224
Mailing Address - Country:US
Mailing Address - Phone:616-647-3777
Mailing Address - Fax:616-647-3776
Practice Address - Street 1:721 3 MILE RD NW STE 200
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-8224
Practice Address - Country:US
Practice Address - Phone:616-647-3777
Practice Address - Fax:616-647-3776
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301084062207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301084062OtherSTATE LICENSE
MI4905461Medicaid
MI4905470Medicaid
MI4905480Medicaid
MI4905452Medicaid
MI0804116382OtherBCBS
MI1598712390OtherGROUP NPI
MI4905443Medicaid
MI0804116382OtherBCBS
MI4905470Medicaid