Healthcare Provider Details

I. General information

NPI: 1104812940
Provider Name (Legal Business Name): BETHANY ANNE VENIT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

881 N CHURCH ST
HAZLETON PA
18201-1837
US

IV. Provider business mailing address

881 N CHURCH ST
HAZLETON PA
18201-1837
US

V. Phone/Fax

Practice location:
  • Phone: 570-455-8557
  • Fax: 570-459-6832
Mailing address:
  • Phone: 570-455-8557
  • Fax: 570-459-6832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD016940E
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0006134960002
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 2
Identifier2511775
Identifier TypeOTHER
Identifier State
Identifier IssuerAETNA
# 3
Identifier027557
Identifier TypeOTHER
Identifier State
Identifier IssuerBS
# 4
Identifier001024
Identifier TypeOTHER
Identifier State
Identifier IssuerFPH
# 5
Identifier16321
Identifier TypeOTHER
Identifier State
Identifier IssuerGHP

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: