Provider Demographics
NPI:1114057080
Name:JACQUES D. BEVERIDGE MD, INC.
Entity Type:Organization
Organization Name:JACQUES D. BEVERIDGE MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:J
Authorized Official - Last Name:ZEBROSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-332-2223
Mailing Address - Street 1:1460 MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-2657
Mailing Address - Country:US
Mailing Address - Phone:307-332-2223
Mailing Address - Fax:
Practice Address - Street 1:1460 MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-2657
Practice Address - Country:US
Practice Address - Phone:307-332-2223
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6275A207V00000X
WY8746.0044367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY9666Medicare PIN