1346311719 NPI number — CLINTON S. BEVERLY MD PC

Table of content: (NPI 1346311719)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346311719 NPI number — CLINTON S. BEVERLY MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLINTON S. BEVERLY MD PC
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:
1346311719
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4047
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MACON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31208-4047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-477-3112
Provider Business Mailing Address Fax Number:
478-477-4840

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
440 CHARTER BLVD
Provider Second Line Business Practice Location Address:
SUITE 3302
Provider Business Practice Location Address City Name:
MACON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31210-4857
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-477-3112
Provider Business Practice Location Address Fax Number:
478-477-4840
Provider Enumeration Date:
11/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BEVERLY
Authorized Official First Name:
CLINTON
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
478-477-3112

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DC0201 . This is a "RAIL ROAD MEDICARE GRP #" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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