Provider Demographics
NPI:1497453252
Name:BEACON BEHAVIORAL PEDIATRIC CLINIC LLC
Entity Type:Organization
Organization Name:BEACON BEHAVIORAL PEDIATRIC CLINIC LLC
Other - Org Name:BEACON BEHAVIORAL PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:ADEKUGBE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-308-1720
Mailing Address - Street 1:8933 WHITE OAK AVE
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-3134
Mailing Address - Country:US
Mailing Address - Phone:617-308-1720
Mailing Address - Fax:
Practice Address - Street 1:8933 WHITE OAK AVE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-3134
Practice Address - Country:US
Practice Address - Phone:219-838-7703
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-21
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care