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General NPI Number Information
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NPI Number | 1619267556
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Entity Type | Individual
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Provider Name | BETHANY TARA SAMUELSON BANNOW MD, MCR
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Gender | Female
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Dates
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Enumeration Date | 04/12/2011
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Last Update Date | 10/07/2025
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Provider Practice Location Address
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Address Line | 10201 CARNEGIE AVE
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City | CLEVELAND
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State | OH
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Zip | 44106-2130
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Country | US
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Telephone | 866-223-8100
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Fax |
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Provider Business Mailing Address
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Address Line | 3096 NW PARKHURST TER
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City | PORTLAND
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State | OR
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Zip | 97229-4078
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Country | US
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Telephone | 509-551-6258
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RH0000X
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Taxonomy Name | Hematology (Internal Medicine) Physician
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License Number | OR186355
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 207RH0003X
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Taxonomy Name | Hematology & Oncology Physician
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License Number | 35.154541
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License Number State | OH
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Taxonomy #3
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Taxonomy Code | 207RH0000X
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Taxonomy Name | Hematology (Internal Medicine) Physician
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License Number | 35.154541
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License Number State | OH
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