Basic Information
Provider Information | |||||||||
NPI: | 1912635723 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BEACON ORTHOPAEDICS & SPORTS MEDICINE LTD | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5040 FOREST DR | ||||||||
Address2: |   | ||||||||
City: | NEW ALBANY | ||||||||
State: | OH | ||||||||
PostalCode: | 430548167 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6148906555 | ||||||||
FaxNumber: | 6145237557 | ||||||||
Practice Location | |||||||||
Address1: | 6785 BOBCAT WAY STE 300 | ||||||||
Address2: |   | ||||||||
City: | DUBLIN | ||||||||
State: | OH | ||||||||
PostalCode: | 430161443 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6148906555 | ||||||||
FaxNumber: | 6145237557 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/10/2022 | ||||||||
LastUpdateDate: | 08/10/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BLANKEMEYER | ||||||||
AuthorizedOfficialFirstName: | ANDREW | ||||||||
AuthorizedOfficialMiddleName: | THOMAS | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 5133547785 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/21/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
No ID Information.