1952440299 NPI number — WILLIS JEROME BEASLEY MC

Table of content: WILLIS JEROME BEASLEY MC (NPI 1952440299)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952440299 NPI number — WILLIS JEROME BEASLEY MC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEASLEY
Provider First Name:
WILLIS
Provider Middle Name:
JEROME
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BEASLEY
Provider Other First Name:
JERRY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1952440299
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
333 W WILCOX
Provider Second Line Business Mailing Address:
STE 303
Provider Business Mailing Address City Name:
SIERRA VISTA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85635
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-378-2613
Provider Business Mailing Address Fax Number:
520-458-5124

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
333 W WILCOX
Provider Second Line Business Practice Location Address:
STE 303
Provider Business Practice Location Address City Name:
SIERRA VISTA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85635
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-378-2613
Provider Business Practice Location Address Fax Number:
520-458-5124
Provider Enumeration Date:
02/05/2007

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: 101YP2500X , with the licence number:  LPC10904 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 307442 . This is a "MHN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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