MEDICARE: DR. BETHANY TARA SAMUELSON BANNOW MD, MCR

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	207RH0000X	Hematology (Internal Medicine) Physician	OR186355	OR
2	207RH0003X	Hematology & Oncology Physician	35.154541	OH
3	207RH0000X	Hematology (Internal Medicine) Physician	35.154541	OH

General Provider Information

NPI Number	:	1619267556
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BETHANY TARA SAMUELSON BANNOW MD, MCR

Provider Business Mailing Address
First Line	:	3096 NW PARKHURST TER
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97229-4078
Country	:	US
Telephone Number	:	509-551-6258
Fax Number	:

Provider Business Practice Location Address
First Line	:	10201 CARNEGIE AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44106-2130
Country	:	US
Telephone Number	:	866-223-8100
Fax Number	:

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

Provider Enumeration Date	:	04/12/2011
Last Update Date	:	10/07/2025

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