Provider Demographics
NPI:1902066673
Name:BETHESDA HOSPICE
Entity Type:Organization
Organization Name:BETHESDA HOSPICE
Other - Org Name:BETHESDA HOSPICE PROFESSIONAL SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRINKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-800-1900
Mailing Address - Street 1:1630 DES PERES RD
Mailing Address - Street 2:SUITE 290
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-1800
Mailing Address - Country:US
Mailing Address - Phone:314-800-1900
Mailing Address - Fax:314-800-1962
Practice Address - Street 1:1630 DES PERES RD
Practice Address - Street 2:SUITE 290
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-1800
Practice Address - Country:US
Practice Address - Phone:314-800-1900
Practice Address - Fax:314-800-1962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-16
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1234Medicare UPIN
MOMA1234001Medicare Oscar/Certification
MA1234Medicare Oscar/Certification