Provider Demographics
NPI:1487747804
Name:BETTENEL MEDICAL GROUP, INC
Entity type:Organization
Organization Name:BETTENEL MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ED
Authorized Official - Middle Name:
Authorized Official - Last Name:BLUMENSTOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-893-1700
Mailing Address - Street 1:365 HAWTHORNE AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3113
Mailing Address - Country:US
Mailing Address - Phone:510-893-1700
Mailing Address - Fax:510-893-0110
Practice Address - Street 1:365 HAWTHORNE AVE STE 301
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3113
Practice Address - Country:US
Practice Address - Phone:510-893-1700
Practice Address - Fax:510-893-0110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG022905207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A41765Medicare UPIN