1164596326 NPI number — BETHESDA CARE EASTGATE

Table of content: (NPI 1679831507)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164596326 NPI number — BETHESDA CARE EASTGATE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BETHESDA CARE EASTGATE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164596326
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10185 WATERSIDE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UNION
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41091-9489
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-384-7221
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4452 EASTGATE BLVD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
CINCINNATI
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45245-1584
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-752-3695
Provider Business Practice Location Address Fax Number:
513-752-3039
Provider Enumeration Date:
11/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LE
Authorized Official First Name:
CHUC
Authorized Official Middle Name:
PHUC
Authorized Official Title or Position:
FACILITY MEDICAL DIRECTOR
Authorized Official Telephone Number:
513-752-3695

Provider Taxonomy Codes

  • Taxonomy code: 261QX0100X , with the licence number:  35071748 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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