Provider Demographics
NPI:1063504207
Name:BEASLEY, ANNETTE D (MD)
Entity Type:Individual
Prefix:MRS
First Name:ANNETTE
Middle Name:D
Last Name:BEASLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14291 NE 47TH AVE
Mailing Address - Street 2:
Mailing Address - City:ANTHONY
Mailing Address - State:FL
Mailing Address - Zip Code:32617-2513
Mailing Address - Country:US
Mailing Address - Phone:812-267-0686
Mailing Address - Fax:
Practice Address - Street 1:1099 MEDICAL CENTER CIR
Practice Address - Street 2:
Practice Address - City:MAYFIELD
Practice Address - State:KY
Practice Address - Zip Code:42066-1159
Practice Address - Country:US
Practice Address - Phone:812-267-0686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01053156A207Q00000X
KY35785207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00058122OtherRAILROAD MEDICARE NUMBER
IN000000292351OtherANTHEM
IN200357830AMedicaid
KYM400068689OtherANTHEM- ICC
KYM400068689OtherANTHEM- ICC
IN208490Medicare ID - Type Unspecified
IN200357830AMedicaid