Provider Demographics
NPI:1083619936
Name:BEECHNAU, TIMOTHY L (DO)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:L
Last Name:BEECHNAU
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 179
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:MI
Mailing Address - Zip Code:49451-0179
Mailing Address - Country:US
Mailing Address - Phone:231-853-6725
Mailing Address - Fax:231-853-6089
Practice Address - Street 1:12520 CROCKERY CREEK DR.
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:MI
Practice Address - Zip Code:49451
Practice Address - Country:US
Practice Address - Phone:231-853-6725
Practice Address - Fax:231-853-6089
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2010-03-08
Deactivation Date:2006-03-18
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
MI008430207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5610010OtherBCN
MA383249263OtherTAX ID
MI4098417OtherAETNA
MI4480790Medicaid
MI383249263OtherPRIORITY HEALTH
MI5610010OtherBCBS
MIE26801Medicare UPIN
MI4480790Medicaid