Basic Information
| Provider Information | |||||||||
| NPI: | 1215272448 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BEAVER MEDICAL GROUP, L.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2200 | ||||||||
| Address2: | |||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923730722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093354148 | ||||||||
| FaxNumber: | 9097932916 | ||||||||
| Practice Location | |||||||||
| Address1: | 245 TERRACINA BLVD. | ||||||||
| Address2: | STE. 102 | ||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923734865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9097922605 | ||||||||
| FaxNumber: | 9093076566 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2012 | ||||||||
| LastUpdateDate: | 11/28/2012 | ||||||||
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| AuthorizedOfficialLastName: | PAYTON | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT/CHIEF MEDICAL OFFICE | ||||||||
| AuthorizedOfficialTelephone: | 9094785162 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.