1861472078 NPI number — MR. MICHAEL BEAUDOIN DPT

Table of content: MR. MICHAEL BEAUDOIN DPT (NPI 1861472078)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861472078 NPI number — MR. MICHAEL BEAUDOIN DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEAUDOIN
Provider First Name:
MICHAEL
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
DPT
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:
1861472078
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2127 RHAWN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19152-3216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-742-8099
Provider Business Mailing Address Fax Number:
215-742-1871

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2127 RHAWN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19152-3216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-742-8099
Provider Business Practice Location Address Fax Number:
215-742-1871
Provider Enumeration Date:
01/23/2006

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: 225100000X , with the licence number:  PTO12778L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1726303 . This is a "BLUE SHIELD PC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 45798 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: Q87414 . This is a "AMERIHEALTH ADMIN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1687414 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 50711 . This is a "US HEALTHCARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2395652000 . This is a "KEYSTONE HEALTH PLAN EAST" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 610675900 . This is a "US DEPT OF LABOR" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2395652000 . This is a "IBC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 3839602 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2395652000 . This is a "KEYSTONE 65" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2395652000 . This is a "AMERIHEALTH HMO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 246902 . This is a "HORIZON NJ PLUS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 30023534 . This is a "KEYSTONE MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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