Basic Information
| Provider Information | |||||||||
| NPI: | 1801207543 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEAVERS | ||||||||
| FirstName: | MELINDA | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 612 N BROAD STREET E | ||||||||
| Address2: | |||||||||
| City: | ANGIER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275018954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063403138 | ||||||||
| FaxNumber: | 7043816841 | ||||||||
| Practice Location | |||||||||
| Address1: | 612 N BROAD STREET E | ||||||||
| Address2: | |||||||||
| City: | ANGIER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275018954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063403138 | ||||||||
| FaxNumber: | 7043816841 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2014 | ||||||||
| LastUpdateDate: | 06/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 2017-01520 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 201059 | NC | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1801207543 | 05 | NC | MEDICAID |