1720260110 NPI number — BRUCE E. BEACHAM, M.D., P.A.

Table of content: (NPI 1720260110)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720260110 NPI number — BRUCE E. BEACHAM, M.D., P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRUCE E. BEACHAM, M.D., 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:
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:
1720260110
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1205 YORK RD
Provider Second Line Business Mailing Address:
SUITE 20
Provider Business Mailing Address City Name:
LUTHERVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21093-6210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-583-2328
Provider Business Mailing Address Fax Number:
410-583-2479

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1205 YORK RD
Provider Second Line Business Practice Location Address:
SUITE 20
Provider Business Practice Location Address City Name:
LUTHERVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21093-6210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-583-2328
Provider Business Practice Location Address Fax Number:
410-583-2479
Provider Enumeration Date:
11/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
STRAIN
Authorized Official First Name:
CAROLYN
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
410-583-2328

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  D0019901 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 010246 . This is a "EHP" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: G847/0001 . This is a "BLUECHOICE/FEDERAL BS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 3204645 . This is a "AETNA HMO" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: KEI3/30272004 . This is a "BC/BS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 193582 . This is a "COVENTRY" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 4067476 . This is a "AETNA PPO" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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