Provider Demographics
NPI:1649215211
Name:BEAVERTON MEDICAL CENTER P.C.
Entity Type:Organization
Organization Name:BEAVERTON MEDICAL CENTER P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:E
Authorized Official - Last Name:BERNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-892-7722
Mailing Address - Street 1:1003 WOODSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:ESSEXVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48732-1234
Mailing Address - Country:US
Mailing Address - Phone:989-892-7722
Mailing Address - Fax:989-892-7455
Practice Address - Street 1:129 W BROWN ST
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:MI
Practice Address - Zip Code:48612-8119
Practice Address - Country:US
Practice Address - Phone:989-435-2937
Practice Address - Fax:989-435-3121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104176826Medicaid
MIO80B610040OtherBCBS
MI=========100OtherCOMMUNITY CHOICE
MI104176826Medicaid
MI=========100OtherCOMMUNITY CHOICE
MIMI1118005Medicare UPIN
MIMI1118006Medicare UPIN
MI104176826Medicaid
MIMI1118Medicare PIN