Healthcare Provider Details

I. General information

NPI: 1508165374
Provider Name (Legal Business Name): BETHANY WOOMER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2011
Last Update Date: 10/11/2020
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

231 E CHESTNUT ST
LOUISVILLE KY
40202-1821
US

IV. Provider business mailing address

3200 E CAMELBACK RD STE 250
PHOENIX AZ
85018-2327
US

V. Phone/Fax

Practice location:
  • Phone: 502-629-4750
  • Fax:
Mailing address:
  • Phone: 602-933-1814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number46869
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number46869
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number56170
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number46869
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: