Healthcare Provider Details

I. General information

NPI: 1225007388
Provider Name (Legal Business Name): BENJAMIN BRYCE BETTERIDGE MD, CAQ SPORTS MEDIC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 07/31/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3733 SO THOMPSON AVE
TACOMA WA
98418
US

IV. Provider business mailing address

2721 SOUNDVIEW DR. WEST
UNIVERSITY PLACE WA
98466
US

V. Phone/Fax

Practice location:
  • Phone: 253-472-4473
  • Fax: 253-474-3056
Mailing address:
  • Phone: 253-283-9954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number2948311205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberMD00043643
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number294831-1205
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License NumberMD00043643
License Number StateWA
# 5
Primary TaxonomyN
Taxonomy Code207PT0002X
TaxonomyMedical Toxicology (Emergency Medicine) Physician
License Number43643
License Number StateWA
# 6
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number43643
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: