Basic Information
| Provider Information | |||||||||
| NPI: | 1285045922 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BECKETT SPRINGS PHYSICIAN GROUP LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8614 SHEPHERD FARM DR | ||||||||
| Address2: | |||||||||
| City: | WEST CHESTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450691128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139429500 | ||||||||
| FaxNumber: | 5137147374 | ||||||||
| Practice Location | |||||||||
| Address1: | 8614 SHEPHERD FARM DR | ||||||||
| Address2: | |||||||||
| City: | WEST CHESTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450691128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139429500 | ||||||||
| FaxNumber: | 5137147374 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2014 | ||||||||
| LastUpdateDate: | 10/11/2021 | ||||||||
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| AuthorizedOfficialLastName: | WARREN | ||||||||
| AuthorizedOfficialFirstName: | GINA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR CREDENTIALING & PAYOR ENRO | ||||||||
| AuthorizedOfficialTelephone: | 5024008480 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 0103989 | 05 | OH | MEDICAID |