Basic Information
Provider Information | |||||||||
NPI: | 1316920986 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BEATY | ||||||||
FirstName: | SEAN | ||||||||
MiddleName: | DALY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 INDEPENDENCE PT STE 202 | ||||||||
Address2: |   | ||||||||
City: | GREENVILLE | ||||||||
State: | SC | ||||||||
PostalCode: | 296154536 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8774062916 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4101 WAGON TRAIL AVE | ||||||||
Address2: |   | ||||||||
City: | LAS VEGAS | ||||||||
State: | NV | ||||||||
PostalCode: | 891184426 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7029424123 | ||||||||
FaxNumber: | 7029424124 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/28/2005 | ||||||||
LastUpdateDate: | 01/11/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 11844 | NV | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | P00342670 | 01 | NV | RR MEDICARE | OTHER | 86080015085259A463 | 01 | AZ | TRICARE WEST | OTHER | 100509912 | 05 | NV |   | MEDICAID | 939788 | 05 | AZ |   | MEDICAID | CC4853 | 01 | NV | BLUE | OTHER |