Healthcare Provider Details

I. General information

NPI: 1619418324
Provider Name (Legal Business Name): WALTER BEITUSCH II CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2017
Last Update Date: 03/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10110 MAD RIVER RD
NEW VIENNA OH
45159-9479
US

IV. Provider business mailing address

10110 MAD RIVER RD
NEW VIENNA OH
45159-9479
US

V. Phone/Fax

Practice location:
  • Phone: 937-527-6089
  • Fax:
Mailing address:
  • Phone: 937-527-6089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.020600
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: