1083619936 NPI number — DR. TIMOTHY L BEECHNAU D.O.

Table of content: DR. TIMOTHY L BEECHNAU D.O. (NPI 1083619936)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083619936 NPI number — DR. TIMOTHY L BEECHNAU D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEECHNAU
Provider First Name:
TIMOTHY
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1083619936
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/18/2006
NPI Reactivation Date:
03/29/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 179
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RAVENNA
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49451-0179
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-853-6725
Provider Business Mailing Address Fax Number:
231-853-6089

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12520 CROCKERY CREEK DR.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RAVENNA
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49451
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-853-6725
Provider Business Practice Location Address Fax Number:
231-853-6089
Provider Enumeration Date:
06/16/2005

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: 207Q00000X , with the licence number:  008430 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5610010 . This is a "BCN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 383249263 . This is a "TAX ID" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 4098417 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4480790 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 383249263 . This is a "PRIORITY HEALTH" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 5610010 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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