MEDICARE: KELBY F. BETHARDS MD PROF. LLC

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	261QP2300X	Primary Care Clinic/Center

Other Identifiers

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

General Provider Information

NPI Number	:	1720067036
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KELBY F. BETHARDS MD PROF. LLC

Provider Business Mailing Address
First Line	:	1017 ROBERTSON ST
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80524-3926
Country	:	US
Telephone Number	:	970-472-5000
Fax Number	:	970-490-6161

Provider Business Practice Location Address
First Line	:	1017 ROBERTSON ST
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80524-3926
Country	:	US
Telephone Number	:	970-472-5000
Fax Number	:	970-490-6161

Authorized Official
Title or Position	:	OWNER
Name	:	KELBY F. BETHARDS
Credential	:	M.D.
Telephone Number	:	970-472-5000

Provider Enumeration Date	:	01/13/2006
Last Update Date	:	03/25/2008

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