1396730479 NPI number — MRS. AMIE DOUGHERTY BEALS PA-C

Table of content: MRS. AMIE DOUGHERTY BEALS PA-C (NPI 1396730479)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396730479 NPI number — MRS. AMIE DOUGHERTY BEALS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEALS
Provider First Name:
AMIE
Provider Middle Name:
DOUGHERTY
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

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:
1396730479
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2905 KILKENNY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45503-7104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-418-8226
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
140 W MAIN STREET
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45502-1312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-398-1066
Provider Business Practice Location Address Fax Number:
937-398-1076
Provider Enumeration Date:
09/15/2005

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: 363A00000X , with the licence number:  50-00-1268 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0067790 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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