Provider Demographics
NPI:1578072906
Name:BEAUMONT MEDICAL GROUP- SPECIALTY SERVICES
Entity Type:Organization
Organization Name:BEAUMONT MEDICAL GROUP- SPECIALTY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. VP BEAUMONT PHYSICIAN PARTNERS
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:MANER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:947-522-1912
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3601 W 13 MILE RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6712
Practice Address - Country:US
Practice Address - Phone:248-898-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-28
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty