Provider Demographics
NPI:1164534871
Name:BEASLEY, STEPHEN EUGENE (PT)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:EUGENE
Last Name:BEASLEY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16914 SHIPMAN ROAD
Mailing Address - Street 2:
Mailing Address - City:CARLINVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62626-2345
Mailing Address - Country:US
Mailing Address - Phone:217-854-2410
Mailing Address - Fax:
Practice Address - Street 1:320 E. CARPENTER STREET
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702
Practice Address - Country:US
Practice Address - Phone:217-744-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.0003233225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK26363Medicare ID - Type UnspecifiedPHYSICAL THERAPIST