Provider Demographics
NPI:1366565194
Name:THE BETHESDA LIFE CENTER, INC.
Entity type:Organization
Organization Name:THE BETHESDA LIFE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MS
Authorized Official - First Name:BETTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:BYRD-GILES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-788-2200
Mailing Address - Street 1:PO BOX 8348
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35218-0348
Mailing Address - Country:US
Mailing Address - Phone:205-788-2200
Mailing Address - Fax:205-788-2201
Practice Address - Street 1:321 19TH STREET ENSLEY
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35218-1642
Practice Address - Country:US
Practice Address - Phone:205-788-2200
Practice Address - Fax:205-788-2201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-08
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1020764207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL110037Medicaid
AL110037Medicaid