Provider Demographics
NPI:1437150117
Name:BEAUCHAMP, KEITH ALAN (DPM)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:ALAN
Last Name:BEAUCHAMP
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 BUTLER ST
Mailing Address - Street 2:P.O. BOX 447
Mailing Address - City:MACON
Mailing Address - State:MO
Mailing Address - Zip Code:63552-1629
Mailing Address - Country:US
Mailing Address - Phone:660-385-4464
Mailing Address - Fax:660-385-1449
Practice Address - Street 1:106 BUTLER ST
Practice Address - Street 2:SUITE A
Practice Address - City:MACON
Practice Address - State:MO
Practice Address - Zip Code:63552-1629
Practice Address - Country:US
Practice Address - Phone:660-385-4464
Practice Address - Fax:660-385-1449
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000737213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO308527605Medicaid
MO626227508OtherMEDICAID DME
MOU62854Medicare UPIN
MO308527605Medicaid
MO480021047Medicare PIN