Provider Demographics
NPI:1629189105
Name:HAMMOND, BETHANIE RAE (MD)
Entity type:Individual
Prefix:
First Name:BETHANIE
Middle Name:RAE
Last Name:HAMMOND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4004 DUPONT CIR STE 230
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4819
Mailing Address - Country:US
Mailing Address - Phone:502-893-1333
Mailing Address - Fax:502-899-9576
Practice Address - Street 1:4004 DUPONT CIR STE 230
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4819
Practice Address - Country:US
Practice Address - Phone:502-893-1333
Practice Address - Fax:502-899-9576
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY475092085R0202X
NE275642085R0202X
KS04368272085R0202X
CO530122085R0202X
MA2464372085R0202X
FLME1660952085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM63780062Medicaid
UT1629189105Medicaid
NE84059792913Medicaid
NE84089712600Medicaid
MT1629189105Medicaid
AZ899230Medicaid
KY7100325960Medicaid
IN200840750Medicare PIN
NE84059792913Medicaid
KY7100325960Medicaid
CO326932YQPGMedicare PIN
MT1629189105Medicaid
NM63780062Medicaid
NENA1214083Medicare PIN
NENA1215083Medicare PIN
KS111257071Medicare PIN
CO326932YQN9Medicare PIN
UT1629189105Medicaid
KSKA3249044Medicare PIN