Provider Demographics
NPI:1346278363
Name:BEAVER MEDICAL GROUP, LP
Entity Type:Organization
Organization Name:BEAVER MEDICAL GROUP, LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:CHEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-793-3311
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 1:7223 CHURCH ST
Practice Address - Street 2:STE C
Practice Address - City:HIGHLAND
Practice Address - State:CA
Practice Address - Zip Code:92346-5869
Practice Address - Country:US
Practice Address - Phone:909-862-1191
Practice Address - Fax:909-796-4158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2019-09-25
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
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ21399ZMedicare ID - Type Unspecified