Healthcare Provider Details

I. General information

NPI: 1598874851
Provider Name (Legal Business Name): ERIC D BETTIS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 06/25/2020
Certification Date: 06/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2003 W BROADWAY SUITE 100
COLUMBIA MO
65203-1111
US

IV. Provider business mailing address

2003 W BROADWAY SUITE 100
COLUMBIA MO
65203-1111
US

V. Phone/Fax

Practice location:
  • Phone: 573-777-5880
  • Fax: 573-777-5875
Mailing address:
  • Phone: 573-777-5880
  • Fax: 573-777-5875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number112989
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number112989
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number112989
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: