Basic Information
Provider Information | |||||||||
NPI: | 1427090281 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BEAVER MEDICAL GROUP, LP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2200 | ||||||||
Address2: |   | ||||||||
City: | REDLANDS | ||||||||
State: | CA | ||||||||
PostalCode: | 923730722 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9094783610 | ||||||||
FaxNumber: | 9094783644 | ||||||||
Practice Location | |||||||||
Address1: | 245 TERRACINA BLVD | ||||||||
Address2: | SUITE # 105 | ||||||||
City: | REDLANDS | ||||||||
State: | CA | ||||||||
PostalCode: | 923734852 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9097929737 | ||||||||
FaxNumber: | 9097964158 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/13/2006 | ||||||||
LastUpdateDate: | 04/30/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: | 09/10/2009 | ||||||||
NPIReactivationDate: | 11/09/2012 | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | OUNANIAN | ||||||||
AuthorizedOfficialFirstName: | LEROY | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 9093354129 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | ZZZ42611Z | 01 |   | MEDICARE PTAN | OTHER |