Provider Demographics
NPI:1407183353
Name:BEASLEY, MICHAEL ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ALAN
Last Name:BEASLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 LONGWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5724
Mailing Address - Country:US
Mailing Address - Phone:617-355-6000
Mailing Address - Fax:617-730-4712
Practice Address - Street 1:319 LONGWOOD AVE
Practice Address - Street 2:DEPT OF SPORTS MEDICINE
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5728
Practice Address - Country:US
Practice Address - Phone:617-355-8597
Practice Address - Fax:617-730-4712
Is Sole Proprietor?:No
Enumeration Date:2009-11-13
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA247169208000000X, 2080S0010X
AZR70720208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ525196Medicaid
MA247169OtherMASSACHUSETTS LICENSE
AZ900001779OtherEMPLOYEE NUMBER