Provider Demographics
NPI:1376541722
Name:BEAUMONT, GARY ROBERT (CRNA)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:ROBERT
Last Name:BEAUMONT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1245
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29116-1245
Mailing Address - Country:US
Mailing Address - Phone:803-395-4497
Mailing Address - Fax:
Practice Address - Street 1:3000 SAINT MATTHEWS RD
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-1442
Practice Address - Country:US
Practice Address - Phone:803-395-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC123746367500000X
TNAPN10192367500000X
VA123746367500000X
KY6045A367500000X
SC4072367500000X
PARN605111367500000X
WV77137367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY74400805Medicaid
SCGP2825Medicaid
TN4274202OtherBLUE CROSS/BLUE SHIELD
KY000000685047OtherBLUE CROSS/BLUE SHIELD
SCGP2825Medicaid
VAVV0318AMedicare PIN