1861472078 NPI number — MR. MICHAEL BEAUDOIN DPT

Table of Contents

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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