Provider Demographics
NPI:1982718607
Name:BETHEL MEDICAL FAMILY PRACTICE,PC
Entity Type:Organization
Organization Name:BETHEL MEDICAL FAMILY PRACTICE,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IMRAN
Authorized Official - Middle Name:
Authorized Official - Last Name:AHMED
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:845-583-5620
Mailing Address - Street 1:1522 STATE ROUTE 17B
Mailing Address - Street 2:PO BOX 570
Mailing Address - City:WHITE LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12786-5428
Mailing Address - Country:US
Mailing Address - Phone:845-583-5620
Mailing Address - Fax:845-583-8084
Practice Address - Street 1:1522 STATE ROUTE 17B
Practice Address - Street 2:
Practice Address - City:WHITE LAKE
Practice Address - State:NY
Practice Address - Zip Code:12786-5428
Practice Address - Country:US
Practice Address - Phone:845-583-5620
Practice Address - Fax:845-583-8084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWLW281Medicare PIN