1104807189 NPI number — MS. HEIDI ANN BEACH ARNP

Employer Identification Number (EIN)	:
Provider Organization Name (Legal Business Name)	:
Provider Last Name (Legal Name)	:	BEACH
Provider First Name	:	HEIDI
Provider Middle Name	:	ANN
Provider Name Prefix Text	:	MS.
Provider Name Suffix Text	:
Provider Credential Text	:	ARNP
Provider Gender Code	:	F

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	:	1104807189
Entity Type Code	:	Individual
Replacement NPI	:
Last Update Date	:	10/09/2007
NPI Deactivation Reason Code	:
NPI Deactivation Date	:
NPI Reactivation Date	:

Provider First Line Business Mailing Address	:	4402 CHURCHMAN AVE
Provider Second Line Business Mailing Address	:	SUITE 305
Provider Business Mailing Address City Name	:	LOUISVILLE
Provider Business Mailing Address State Name	:	KY
Provider Business Mailing Address Postal Code	:	402151190
Provider Business Mailing Address Country Code	:	US
Provider Business Mailing Address Telephone Number	:	5023689590
Provider Business Mailing Address Fax Number	:	5023689616

Provider First Line Business Practice Location Address	:	4402 CHURCHMAN AVE
Provider Second Line Business Practice Location Address	:	SUITE 305
Provider Business Practice Location Address City Name	:	LOUISVILLE
Provider Business Practice Location Address State Name	:	KY
Provider Business Practice Location Address Postal Code	:	402151190
Provider Business Practice Location Address Country Code	:	US
Provider Business Practice Location Address Telephone Number	:	5023689590
Provider Business Practice Location Address Fax Number	:	5023689616
Provider Enumeration Date	:	11/08/2005

Authorized Official Last Name	:
Authorized Official First Name	:
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• Taxonomy code: 363LA2200X , with the licence number:  3421P , registered in the state of KY .

• Identifier: 2439614000 . This is a "PASSPORT ADVANTAGE" identifier . This identifiers is of the category "".
• Identifier: P25517 , issued by the state of ( KY ) . This identifiers is of the category "".
• Identifier: 1161890 . This is a "PASSPORT" identifier . This identifiers is of the category "".
• Identifier: 1338507 . This is a "PROVIDER ID" identifier , issued by the state of ( KY ) . This identifiers is of the category "".
• Identifier: 000000187104 . This is a "ANTHEM" identifier . This identifiers is of the category "".