Provider Demographics
NPI:1508821000
Name:BEAUDOIN, JEFFREY BLAIR (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:BLAIR
Last Name:BEAUDOIN
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 1:521 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2266
Mailing Address - Country:US
Mailing Address - Phone:231-487-1900
Mailing Address - Fax:231-348-0984
Practice Address - Street 1:521 MONROE ST
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2266
Practice Address - Country:US
Practice Address - Phone:231-487-1900
Practice Address - Fax:231-348-0984
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301057924208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI020B41012OtherBCBS MI
MI0B41012OtherBCN
MI020043565OtherRAILROAD MEDICARE
MI4084724Medicaid
MI0B41012OtherBCN
MI4084724Medicaid