Provider Demographics
NPI:1164423935
Name:BEACH, ANDREW C (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:C
Last Name:BEACH
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:PO BOX 908
Mailing Address - Street 2:
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857-0908
Mailing Address - Country:US
Mailing Address - Phone:573-888-0001
Mailing Address - Fax:573-888-0006
Practice Address - Street 1:211 TEACO RD
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-3236
Practice Address - Country:US
Practice Address - Phone:573-888-0001
Practice Address - Fax:573-888-0006
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-03
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000151544208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO139325OtherBCBS
MO205068406Medicaid
H22804Medicare UPIN
MO000094882Medicare PIN
MO205068406Medicaid