1104828979 NPI number — BRIAN BEALS MD

Table of content: BRIAN BEALS MD (NPI 1104828979)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104828979 NPI number — BRIAN BEALS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEALS
Provider First Name:
BRIAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1104828979
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/15/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
133 PLEASANT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BERLIN
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03570-2006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-752-2040
Provider Business Mailing Address Fax Number:
603-752-1709

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2 BROADWAY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GORHAM
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03581-1502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-466-2741
Provider Business Practice Location Address Fax Number:
603-466-2953
Provider Enumeration Date:
08/11/2005

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: 208000000X , with the licence number:  9177 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: RE7915 . This is a "MEDICARE NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 784908 . This is a "MVP HEALTHCARE" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 0109720YPNH02 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 30007014 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5756404001 . This is a "CIGNA HEALTHCARE" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 5830418 . This is a "AETNA GROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3072544 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9177 . This is a "STATE LICENSE #" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".




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