Provider Demographics
NPI:1104856087
Name:BEARDSLEY, BRYAN JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:JAMES
Last Name:BEARDSLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 WARNER DR
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4441
Mailing Address - Country:US
Mailing Address - Phone:208-743-3523
Mailing Address - Fax:208-746-8471
Practice Address - Street 1:320 WARNER DR
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4441
Practice Address - Country:US
Practice Address - Phone:208-743-3523
Practice Address - Fax:208-746-8471
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9722207X00000X
WAMD00044939207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807636400Medicaid
WA8169918Medicaid
ID76800OtherBLUECROSS OF IDAHO
ID000010159447OtherREGENCE BLUESHIELD
IDP00381742Medicare PIN
ID000010159447OtherREGENCE BLUESHIELD
ID76800OtherBLUECROSS OF IDAHO
ID807636400Medicaid