Provider Demographics
NPI:1497928469
Name:RAVENNA FAMILY PRACTICE, P.C.
Entity Type:Organization
Organization Name:RAVENNA FAMILY PRACTICE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BEECHNAU
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:231-853-2954
Mailing Address - Street 1:12520 CROCKERY CREEK DR.
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:MI
Mailing Address - Zip Code:49451
Mailing Address - Country:US
Mailing Address - Phone:231-853-2954
Mailing Address - Fax:231-853-6089
Practice Address - Street 1:12520 CROCKERY CREEK DR.
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:MI
Practice Address - Zip Code:49451
Practice Address - Country:US
Practice Address - Phone:231-853-2954
Practice Address - Fax:231-853-6089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI008430207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4480790Medicaid
0N86270Medicare PIN
MIE26801Medicare UPIN