Provider Demographics
NPI:1447240312
Name:BEAVERS, MICHAEL LELAND (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LELAND
Last Name:BEAVERS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-1045
Mailing Address - Country:US
Mailing Address - Phone:410-641-9450
Mailing Address - Fax:410-641-9515
Practice Address - Street 1:9733 HEALTHWAY DR
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-1155
Practice Address - Country:US
Practice Address - Phone:410-641-9450
Practice Address - Fax:410-641-9515
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0057008207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKP95118MMedicare ID - Type Unspecified
MDH40611Medicare UPIN