Basic Information
| Provider Information | |||||||||
| NPI: | 1275570830 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BEAVER MEDICAL GROUP, LP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | BEAVER ADVANTAGE HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10069 | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924230069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093354188 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1600 E CITRUS AVE | ||||||||
| Address2: | SUITE # A | ||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923744270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9097943682 | ||||||||
| FaxNumber: | 9097964158 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 02/19/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 09/10/2009 | ||||||||
| NPIReactivationDate: | 11/09/2012 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHEN | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 0979333119 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BEAVER MEDICAL GROUP, LP | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.