Provider Demographics
NPI:1639154768
Name:BEAUDOING, ROGER (DO)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:BEAUDOING
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5392 MANGUS
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:MI
Mailing Address - Zip Code:48612
Mailing Address - Country:US
Mailing Address - Phone:989-435-4669
Mailing Address - Fax:
Practice Address - Street 1:703 N MCEWAN ST
Practice Address - Street 2:
Practice Address - City:CLARE
Practice Address - State:MI
Practice Address - Zip Code:48617-1440
Practice Address - Country:US
Practice Address - Phone:989-386-5120
Practice Address - Fax:989-802-8880
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011345207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI080D410020OtherBLUE CROSS BLUE SHIELD
MI158100275OtherBLUE CROSS BLUE SHIELD
MI4455090Medicaid
MI4487254Medicaid
MIMI1609058Medicare PIN
MIF59291Medicare UPIN
MI4487254Medicaid
MIM57650054Medicare PIN