Provider Demographics
NPI:1629037049
Name:BEAVERSON, PHILIP REID (PT)
Entity Type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:REID
Last Name:BEAVERSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 PENNSYLVANIA PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46280-1393
Mailing Address - Country:US
Mailing Address - Phone:317-817-1200
Mailing Address - Fax:317-817-1220
Practice Address - Street 1:201 PENNSYLVANIA PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46280-1393
Practice Address - Country:US
Practice Address - Phone:317-817-1200
Practice Address - Fax:317-817-1220
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05006716A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000337432OtherANTHEM BCBS
IN200869380Medicaid
IN151560CCCCMedicare PIN
IN151540IIMedicare PIN
IN151560CCCCMedicare PIN