Provider Demographics
NPI:1275570830
Name:BEAVER MEDICAL GROUP, LP
Entity Type:Organization
Organization Name:BEAVER MEDICAL GROUP, LP
Other - Org Name:BEAVER ADVANTAGE HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:T
Authorized Official - Last Name:CHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:097-933-3119
Mailing Address - Street 1:PO BOX 10069
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-0069
Mailing Address - Country:US
Mailing Address - Phone:909-335-4188
Mailing Address - Fax:
Practice Address - Street 1:1600 E CITRUS AVE
Practice Address - Street 2:SUITE # A
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-4270
Practice Address - Country:US
Practice Address - Phone:909-794-3682
Practice Address - Fax:909-796-4158
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEAVER MEDICAL GROUP, LP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-01
Last Update Date:2020-02-19
Deactivation Date:2009-09-10
Deactivation Code:
Reactivation Date:2012-11-09
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ42611ZMedicare ID - Type Unspecified