Provider Demographics
NPI:1558080655
Name:BEACH, SAM L
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:L
Last Name:BEACH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 MOUNT PLEASANT PARK APT 2
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14608-2966
Mailing Address - Country:US
Mailing Address - Phone:585-489-1438
Mailing Address - Fax:
Practice Address - Street 1:320 N GOODMAN ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14607-1185
Practice Address - Country:US
Practice Address - Phone:585-329-1489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-23
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist