Provider Demographics
NPI: | 1952390551 |
---|---|
Name: | BETKA, ERIC J |
Entity type: | Individual |
Prefix: | |
First Name: | ERIC |
Middle Name: | J |
Last Name: | BETKA |
Suffix: | |
Gender: | M |
Credentials: | |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 8701 DARROW RD |
Mailing Address - Street 2: | |
Mailing Address - City: | TWINSBURG |
Mailing Address - State: | OH |
Mailing Address - Zip Code: | 44087-2105 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 330-888-4000 |
Mailing Address - Fax: | 440-774-5707 |
Practice Address - Street 1: | 8701 DARROW RD |
Practice Address - Street 2: | |
Practice Address - City: | TWINSBURG |
Practice Address - State: | OH |
Practice Address - Zip Code: | 44087-2105 |
Practice Address - Country: | US |
Practice Address - Phone: | 330-888-4000 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2005-10-17 |
Last Update Date: | 2023-02-28 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OH | 50.001576 | 207R00000X |
OH | OH-1576 | 363AM0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | Group - Single Specialty |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Single Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OH | BEPA16341 | Medicare ID - Type Unspecified |