MEDICARE: BETH HAAS RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	359933	OH

General Provider Information

NPI Number	:	1619255098
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BETH HAAS RN

Provider Business Mailing Address
First Line	:	9764 STATE ROUTE 125
Second Line	:
City	:	RUSSELLVILLE
State	:	OH
Zip	:	45168-8941
Country	:	US
Telephone Number	:	937-373-1183
Fax Number	:

Provider Business Practice Location Address
First Line	:	9764 STATE ROUTE 125
Second Line	:
City	:	RUSSELLVILLE
State	:	OH
Zip	:	45168-8941
Country	:	US
Telephone Number	:	937-373-1183
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2011
Last Update Date	:	05/28/2015

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