Provider Demographics
NPI:1871528943
Name:BETHEL, COLIN A (MD)
Entity type:Individual
Prefix:
First Name:COLIN
Middle Name:A
Last Name:BETHEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 785361
Mailing Address - Street 2:PEDIATRIC SURGERY GROUP
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178
Mailing Address - Country:US
Mailing Address - Phone:888-282-3652
Mailing Address - Fax:973-549-6079
Practice Address - Street 1:2130 MILLBURN AVENUE
Practice Address - Street 2:SUITE C-1
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040
Practice Address - Country:US
Practice Address - Phone:888-287-3652
Practice Address - Fax:973-549-6079
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA065598002086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7346409Medicaid
NJ7346409Medicaid