Provider Demographics
NPI:1194907550
Name:SHORTRIDGE, BETH A (MD)
Entity type:Individual
Prefix:DR
First Name:BETH
Middle Name:A
Last Name:SHORTRIDGE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:
Other - Last Name:HAAK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1 GUTHRIE SQ
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-888-5858
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:1011 N ELMER AVE
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840-1832
Practice Address - Country:US
Practice Address - Phone:570-887-3070
Practice Address - Fax:570-887-3382
Is Sole Proprietor?:No
Enumeration Date:2007-11-28
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD038026E208000000X, 208D00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3607704Medicaid
PA001243228Medicaid
MD4138252Medicaid
686123SAJMedicare PIN
F98854Medicare UPIN