Basic Information
| Provider Information | |||||||||
| NPI: | 1508132283 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BEAULAC | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15855 NINETEEN MILE RD. | ||||||||
| Address2: | HENRY FORD MACOMB HOSPITAL | ||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480386608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867579707 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15855 NINETEEN MILE RD. | ||||||||
| Address2: | HENRY FORD MACOMB HOSPITAL | ||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867579707 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2012 | ||||||||
| LastUpdateDate: | 02/13/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 5101019890 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0300X | 5101019890 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
No ID Information.