Provider Demographics
NPI:1598967580
Name:BEACHUM, GARY HAMPTON (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:HAMPTON
Last Name:BEACHUM
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 1:101 E STATE ST
Mailing Address - Street 2:MAIL BOX 192
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-5543
Mailing Address - Country:US
Mailing Address - Phone:919-450-7666
Mailing Address - Fax:
Practice Address - Street 1:101 E STATE ST
Practice Address - Street 2:MAIL BOX 192
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-5543
Practice Address - Country:US
Practice Address - Phone:919-450-7666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY192184-1207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F49552Medicare UPIN