Basic Information
| Provider Information | |||||||||
| NPI: | 1730530973 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CCMA BEAUMONT PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18181 OAKWOOD BLVD | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481245032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132715565 | ||||||||
| FaxNumber: | 3132711053 | ||||||||
| Practice Location | |||||||||
| Address1: | 18181 OAKWOOD BLVD | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481245032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132715565 | ||||||||
| FaxNumber: | 3132711053 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2016 | ||||||||
| LastUpdateDate: | 03/12/2021 | ||||||||
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| AuthorizedOfficialLastName: | HAYDON | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3132715565 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 03/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
No ID Information.