Provider Demographics
NPI:1992729503
Name:MT BETHEL MEDICAL CENTER LLC
Entity type:Organization
Organization Name:MT BETHEL MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO MOUNT BETHEL MEDICAL CENTER LLC
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:A
Authorized Official - Last Name:RASO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-897-7559
Mailing Address - Street 1:PO BOX 43
Mailing Address - Street 2:10 MOUNT BETHEL PLAZA
Mailing Address - City:MOUNT BETHEL
Mailing Address - State:PA
Mailing Address - Zip Code:18343-0043
Mailing Address - Country:US
Mailing Address - Phone:570-897-7559
Mailing Address - Fax:570-897-7567
Practice Address - Street 1:10 MOUNT BETHEL PLZ
Practice Address - Street 2:
Practice Address - City:MOUNT BETHEL
Practice Address - State:PA
Practice Address - Zip Code:18343-5212
Practice Address - Country:US
Practice Address - Phone:570-897-7559
Practice Address - Fax:570-897-7567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD053686L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
110130795OtherPALMETTO GBA - RAILROAD MEDICARE
50017380OtherCAPITAL BLUE CROSS
1512446OtherHIGHMARK BLUE SHIELD
5843921OtherCIGNA
110130795OtherPALMETTO GBA - RAILROAD MEDICARE
G08884Medicare UPIN