Provider Demographics
NPI:1407033400
Name:GLEN A BEEDE DPM PA
Entity Type:Organization
Organization Name:GLEN A BEEDE DPM PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:BEEDE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:817-763-9383
Mailing Address - Street 1:5521 BELLAIRE DR S STE 116
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-5855
Mailing Address - Country:US
Mailing Address - Phone:817-763-9383
Mailing Address - Fax:817-763-9385
Practice Address - Street 1:5521 BELLAIRE DR S STE 116
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-5855
Practice Address - Country:US
Practice Address - Phone:817-763-9383
Practice Address - Fax:817-763-9385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1317261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU56678Medicare UPIN
TX8F21956Medicare PIN
TX6148900001Medicare NSC