Provider Demographics
NPI:1578240511
Name:BEAVERTON FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:BEAVERTON FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ETHAN
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-590-4137
Mailing Address - Street 1:12815 HIGHWAY 278
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:AL
Mailing Address - Zip Code:35544-2954
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12815 HIGHWAY 278
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:AL
Practice Address - Zip Code:35544-2954
Practice Address - Country:US
Practice Address - Phone:205-606-1200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-30
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty