Healthcare Provider Details

I. General information

NPI: 1487655338
Provider Name (Legal Business Name): CHARLES N. BETHMANN P.A.-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 01/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 SALLITT DR SUITE E
STEVENSVILLE MD
21666-2156
US

IV. Provider business mailing address

1111 BENFIELD BLVD SUITE 200
MILLERSVILLE MD
21108-3002
US

V. Phone/Fax

Practice location:
  • Phone: 410-643-7800
  • Fax: 410-643-7568
Mailing address:
  • Phone: 410-729-5100
  • Fax: 410-729-5156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number010207M14
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: