Provider Demographics
NPI:1497703607
Name:BEAULIEU, LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:LYNN
Middle Name:
Last Name:BEAULIEU
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 1:4199 APACHE PLUME DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-7664
Mailing Address - Country:US
Mailing Address - Phone:719-282-4321
Mailing Address - Fax:
Practice Address - Street 1:175 S UNION BLVD
Practice Address - Street 2:SUITE 305
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3113
Practice Address - Country:US
Practice Address - Phone:719-365-6881
Practice Address - Fax:719-365-6877
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO31824174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOA104028OtherMEMORIAL HOSPITAL
CO81671709Medicaid
CO495198OtherMHS MEDICARE PIN
COBEB8948OtherBLUE SHIELD
COBEB8948OtherBLUE SHIELD
COCOA104028OtherMEMORIAL HOSPITAL