Provider Demographics
NPI:1619267556
Name:SAMUELSON BANNOW, BETHANY TARA (MD, MCR)
Entity type:Individual
Prefix:DR
First Name:BETHANY
Middle Name:TARA
Last Name:SAMUELSON BANNOW
Suffix:
Gender:F
Credentials:MD, MCR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3096 NW PARKHURST TER
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-4078
Mailing Address - Country:US
Mailing Address - Phone:509-551-6258
Mailing Address - Fax:
Practice Address - Street 1:10201 CARNEGIE AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-2130
Practice Address - Country:US
Practice Address - Phone:866-223-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-12
Last Update Date:2025-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROR186355207RH0000X
WAMD60469202207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology