1609881036 NPI number — BRUCE W BEAUCHAMP DO

Table of content: BRUCE W BEAUCHAMP DO (NPI 1609881036)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609881036 NPI number — BRUCE W BEAUCHAMP DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEAUCHAMP
Provider First Name:
BRUCE
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609881036
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/18/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2521 DELORES LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH BEND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97459-1524
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-751-1434
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4021 S 700 E
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84107-2192
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-211-4971
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/31/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  16476 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207L00000X , with the licence number: 1260 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: 10096 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: 5697 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: 3891 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: 0.198 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: 1499 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: DO 116462 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 28761 . This is a "ND BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 1417978057 . This is a "DEPT OF HUMAN SERVICES" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: A06171050226 . This is a "PREFERRED ONE" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 14198 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20-03471 . This is a "MEDICA" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".