Basic Information
| Provider Information | |||||||||
| NPI: | 1235441528 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BECKHOLT | ||||||||
| FirstName: | KRISTY | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SNELL | ||||||||
| OtherFirstName: | KRISTY | ||||||||
| OtherMiddleName: | ANNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1215 E. MICHIGAN AVE 7TH FL TOWER WEST | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173643380 | ||||||||
| FaxNumber: | 5173643399 | ||||||||
| Practice Location | |||||||||
| Address1: | 1215 E MICHIGAN AVE 7TH FL TOWER WEST | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173643380 | ||||||||
| FaxNumber: | 5173643399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2010 | ||||||||
| LastUpdateDate: | 09/07/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101018602 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207QG0300X | 5101018602 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1235441528 | 05 | MI | MEDICAID | 5330585 | 01 | MI | BCBS PIN | OTHER |