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NPI Code Detail

MEDICARE: MRS. BETHANY JOY TILLEMA PA-C

MEDICARE: MRS. BETHANY JOY TILLEMA PA-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12255A2300XAthletic Trainer2601000292MI
2363A00000XPhysician Assistant5601008127MI

General Provider Information

NPI Number : 1417920331
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. BETHANY JOY TILLEMA PA-C
Provider Business Mailing Address
First Line : 100 MICHIGAN ST NE
Second Line : MC 845
City : GRAND RAPIDS
State : MI
Zip : 49503-2560
Country : US
Telephone Number : 616-486-6790
Fax Number :
Provider Business Practice Location Address
First Line : 15100 WHITTAKER WAY
Second Line :
City : GRAND HAVEN
State : MI
Zip : 49417-8696
Country : US
Telephone Number : 616-935-6260
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/10/2006
Last Update Date : 09/05/2023

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