Provider Demographics
NPI:1164433108
Name:BEAUMONT, DALE WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:WILLIAM
Last Name:BEAUMONT
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 1:42633 GARFIELD RD STE 318
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-5033
Mailing Address - Country:US
Mailing Address - Phone:586-286-7670
Mailing Address - Fax:586-286-5179
Practice Address - Street 1:42633 GARFIELD RD STE 318
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-5033
Practice Address - Country:US
Practice Address - Phone:586-286-7670
Practice Address - Fax:586-286-5179
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301034186207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1164433108OtherINDIVIDUAL NPI
MI0504232OtherMEDICARE LEGACY PROVIDER NUMBER FOR INDIVIDUAL NPI
MIP57770001OtherNPI INDIVIDUAL PROVIDER TRANSACTION ACCESS NUMBER(PTAN)
MI0P57770OtherNPI GROUP PROVIDER TRANSACTION ACCESS NUMBER(PTAN)
MI2132199Medicaid
MI1144495193OtherNPI GROUP NUMBER
MIB44670Medicare UPIN
MIP57770001OtherNPI INDIVIDUAL PROVIDER TRANSACTION ACCESS NUMBER(PTAN)