1821097510 NPI number — MR. JOSHUA JEREMIAH BEARDSLEY PA-C

Table of content: MR. JOSHUA JEREMIAH BEARDSLEY PA-C (NPI 1821097510)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821097510 NPI number — MR. JOSHUA JEREMIAH BEARDSLEY PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEARDSLEY
Provider First Name:
JOSHUA
Provider Middle Name:
JEREMIAH
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

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:
1821097510
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 S HERLONG AVE
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
ROCK HILL
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29732-3399
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-327-8500
Provider Business Mailing Address Fax Number:
803-327-8505

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 S HERLONG AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
ROCK HILL
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29732-3399
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-327-8500
Provider Business Practice Location Address Fax Number:
803-327-8505
Provider Enumeration Date:
07/15/2005

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: 363A00000X , with the licence number:  103940 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X , with the licence number: PA936 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00193752 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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