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NPI Code Detail

MEDICARE: LORI MARIE BETHKE MD

MEDICARE: LORI MARIE BETHKE MD
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
1207Q00000XFamily Medicine Physician43604MN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1639193261
Entity Type Code : Individual
Provider Name (Legal Business Name) : LORI MARIE BETHKE MD
Provider Business Mailing Address
First Line : 2025 SLOAN PL STE 35
Second Line :
City : SAINT PAUL
State : MN
Zip : 55117-2092
Country : US
Telephone Number : 651-772-1572
Fax Number : 651-772-1889
Provider Business Practice Location Address
First Line : 3550 LABORE RD STE 7
Second Line :
City : VADNAIS HEIGHTS
State : MN
Zip : 55110-5113
Country : US
Telephone Number : 651-766-0520
Fax Number : 651-766-9451
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/27/2006
Last Update Date : 04/16/2019

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