Provider Demographics
NPI:1629068960
Name:BEACH, KATHERINE GLEASON (CNM)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:GLEASON
Last Name:BEACH
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 US ROUTE 1
Mailing Address - Street 2:BUILDING C
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-7609
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:100 BRICKHILL AVE
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-1999
Practice Address - Country:US
Practice Address - Phone:207-761-1502
Practice Address - Fax:207-774-2015
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNM82029367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME040608OtherANTHEM
ME420000116OtherGBA PALMETTO/RR MEDICARE
ME274220099Medicaid
NH30347515Medicaid
ME274220099Medicaid
ME420000116OtherGBA PALMETTO/RR MEDICARE
MEMM7742Medicare PIN
MEMM774201Medicare PIN