Provider Demographics
NPI:1144433152
Name:BRUCE A BETHANCOURT MD PC
Entity type:Organization
Organization Name:BRUCE A BETHANCOURT MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BETHANCOURT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-254-1429
Mailing Address - Street 1:5922 E CHENEY DR
Mailing Address - Street 2:
Mailing Address - City:PARADISE VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85253-3574
Mailing Address - Country:US
Mailing Address - Phone:602-778-6789
Mailing Address - Fax:602-778-3513
Practice Address - Street 1:4400 N 32ND ST STE 140
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-3964
Practice Address - Country:US
Practice Address - Phone:602-254-1429
Practice Address - Fax:602-778-3513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12752207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ22808Medicare ID - Type Unspecified
AZ22807Medicare ID - Type Unspecified
AZ22806Medicare PIN
AZG60325Medicare UPIN
AZD36561Medicare UPIN