Healthcare Provider Details

I. General information

NPI: 1235195850
Provider Name (Legal Business Name): JOSEPH K BETHLE PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2006
Last Update Date: 02/01/2022
Certification Date: 06/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 DOUG WHITE DR STE 130
MYRTLE BEACH SC
29572-4180
US

IV. Provider business mailing address

920 DOUG WHITE DR STE 130
MYRTLE BEACH SC
29572-4180
US

V. Phone/Fax

Practice location:
  • Phone: 843-848-1440
  • Fax: 843-839-1654
Mailing address:
  • Phone: 843-848-1440
  • Fax: 843-839-1654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberA630
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number630
License Number StateSC

VII. Legacy identifiers

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

# 1
IdentifierQM0497
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: