1679505176 NPI number — DR. MARSHA R BEAL M.D.

Table of content: DR. MARSHA R BEAL M.D. (NPI 1679505176)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679505176 NPI number — DR. MARSHA R BEAL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEAL
Provider First Name:
MARSHA
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HUDSON-BEAL
Provider Other First Name:
MARSHA
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1679505176
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4777 E OUTER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48234-3241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-369-1960
Provider Business Mailing Address Fax Number:
313-369-1977

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20548 FENKELL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48223-1613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-255-3333
Provider Business Practice Location Address Fax Number:
313-255-4335
Provider Enumeration Date:
07/07/2006

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: 207Q00000X , with the licence number:  4301407503 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4763959 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 08-0824561-2 . This is a "BCBSM PIN NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1396839981 . This is a "WALLER HEALTH CARE FOR THE HOMELESS CENTER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1144371279 . This is a "ADVANTAGE FAMILY HEALTH CENTER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1871645309 . This is a "THEA BOWMAN COMMUNITY HEALTH CENTER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com