Provider Demographics
NPI:1396964938
Name:BETZOLD, BRENT (PT)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:BETZOLD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3495 S CENTER RD
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48519-1455
Mailing Address - Country:US
Mailing Address - Phone:810-424-2007
Mailing Address - Fax:810-743-1099
Practice Address - Street 1:4901 TOWNE CENTRE RD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-2841
Practice Address - Country:US
Practice Address - Phone:989-498-5100
Practice Address - Fax:989-498-0197
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011432225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP45540027Medicare PIN
MIP45530027Medicare PIN