Basic Information
Provider Information | |||||||||
NPI: | 1700878279 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BEVERLY | ||||||||
FirstName: | STEVEN | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5546 | ||||||||
Address2: |   | ||||||||
City: | DENVER | ||||||||
State: | CO | ||||||||
PostalCode: | 802175546 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8014753240 | ||||||||
FaxNumber: | 8014753241 | ||||||||
Practice Location | |||||||||
Address1: | 4403 HARRISON BLVD | ||||||||
Address2: | STE 4650 | ||||||||
City: | OGDEN | ||||||||
State: | UT | ||||||||
PostalCode: | 844033271 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8014753240 | ||||||||
FaxNumber: | 8014753241 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/19/2005 | ||||||||
LastUpdateDate: | 06/19/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/19/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 37011 | KY | N |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 207VG0400X | 37011 | KY | N |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 207VG0400X | 8836143-1205 | UT | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
No ID Information.