Provider Demographics
NPI:1588230510
Name:BEAUDRY, RUSSELL THOMAS
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:THOMAS
Last Name:BEAUDRY
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 1:97 S 4TH ST STE C
Mailing Address - Street 2:
Mailing Address - City:ISHPEMING
Mailing Address - State:MI
Mailing Address - Zip Code:49849-2168
Mailing Address - Country:US
Mailing Address - Phone:906-228-9699
Mailing Address - Fax:906-228-0505
Practice Address - Street 1:241 WRIGHT ST
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-1955
Practice Address - Country:US
Practice Address - Phone:906-228-7611
Practice Address - Fax:906-228-8156
Is Sole Proprietor?:No
Enumeration Date:2021-06-01
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist