Provider Demographics
NPI:1346311719
Name:CLINTON S. BEVERLY MD PC
Entity Type:Organization
Organization Name:CLINTON S. BEVERLY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLINTON
Authorized Official - Middle Name:S
Authorized Official - Last Name:BEVERLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-477-3112
Mailing Address - Street 1:PO BOX 4047
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31208-4047
Mailing Address - Country:US
Mailing Address - Phone:478-477-3112
Mailing Address - Fax:478-477-4840
Practice Address - Street 1:440 CHARTER BLVD
Practice Address - Street 2:SUITE 3302
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-4857
Practice Address - Country:US
Practice Address - Phone:478-477-3112
Practice Address - Fax:478-477-4840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADC0201OtherRAIL ROAD MEDICARE GRP #
GAGRP6612Medicare ID - Type UnspecifiedMEDICARE GROUP #