1689778714 NPI number — BEACON MEDICAL GROUP, P.A.

Table of content: (NPI 1689778714)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689778714 NPI number — BEACON MEDICAL GROUP, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEACON MEDICAL GROUP, P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LONGNECK FAMILY PRACTICE, PA
Provider Other Organization Name Type Code:
4
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:
1689778714
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26744 JOHN J WILLIAMS HWY
Provider Second Line Business Mailing Address:
OAK ORCHARD PROF SUITES #3
Provider Business Mailing Address City Name:
MILLSBORO
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19966-4645
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-947-9767
Provider Business Mailing Address Fax Number:
302-947-9558

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
26744 JOHN J WILLIAMS HWY
Provider Second Line Business Practice Location Address:
OAK ORCHARD PROF SUITES #3
Provider Business Practice Location Address City Name:
MILLSBORO
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19966-4667
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-947-9767
Provider Business Practice Location Address Fax Number:
302-947-9558
Provider Enumeration Date:
09/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HAWTOF
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRES
Authorized Official Telephone Number:
320-947-9767

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0001150402 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".




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