Provider Demographics
NPI:1114238425
Name:BEASON, KEVIN LEE (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:LEE
Last Name:BEASON
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 1:10161 ROAD 1343
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350-0000
Mailing Address - Country:US
Mailing Address - Phone:601-955-7829
Mailing Address - Fax:
Practice Address - Street 1:10151 ROAD 1343
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:MS
Practice Address - Zip Code:39350-4101
Practice Address - Country:US
Practice Address - Phone:601-955-7829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-01
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-2284207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS302I930424Medicare UPIN