1033647953 NPI number — KATHERINE ANN BEBEAU MD

Table of content: JILL JUERS LICSW (NPI 1619271418)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033647953 NPI number — KATHERINE ANN BEBEAU MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEBEAU
Provider First Name:
KATHERINE
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BEBEAU
Provider Other First Name:
KALI
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1033647953
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
ST. JOSEPH'S/ CANDLER- MANAGED CARE DEPT.
Provider Second Line Business Mailing Address:
836 EAST 65TH STREET, BLDG 22
Provider Business Mailing Address City Name:
SAVANNAH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-819-2622
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5354 REYNOLDS ST STE 518
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAVANNAH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31405-6012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-819-9650
Provider Business Practice Location Address Fax Number:
912-819-9651
Provider Enumeration Date:
05/24/2017

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: 207V00000X , with the licence number:  89621 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207V00000X , with the licence number: LL40966 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 89621 . This is a "GA MEDICAL LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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