Basic Information
Provider Information | |||||||||
NPI: | 1013139146 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BEATY | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | J | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.T. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1808 W BELTLINE HWY | ||||||||
Address2: |   | ||||||||
City: | MADISON | ||||||||
State: | WI | ||||||||
PostalCode: | 537132334 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6082501497 | ||||||||
FaxNumber: | 6082501384 | ||||||||
Practice Location | |||||||||
Address1: | 1300 S CENTURY AVE | ||||||||
Address2: |   | ||||||||
City: | WAUNAKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 535972386 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6088494315 | ||||||||
FaxNumber: | 6088501606 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/02/2007 | ||||||||
LastUpdateDate: | 10/30/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/30/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 13230-24 | WI | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 225100000X | 596 | NE | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 2251G0304X | 10075-024 | WI | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Geriatrics | 225100000X | 10075 | WI | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.