Provider Demographics
NPI:1679505176
Name:BEAL, MARSHA R (MD)
Entity Type:Individual
Prefix:DR
First Name:MARSHA
Middle Name:R
Last Name:BEAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARSHA
Other - Middle Name:
Other - Last Name:HUDSON-BEAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4777 E OUTER DR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48234-3241
Mailing Address - Country:US
Mailing Address - Phone:313-369-1960
Mailing Address - Fax:313-369-1977
Practice Address - Street 1:20548 FENKELL ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-1613
Practice Address - Country:US
Practice Address - Phone:313-255-3333
Practice Address - Fax:313-255-4335
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301407503207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4763959Medicaid
MI08-0824561-2OtherBCBSM PIN NUMBER
MI1396839981OtherWALLER HEALTH CARE FOR THE HOMELESS CENTER
MI1144371279OtherADVANTAGE FAMILY HEALTH CENTER
MI1871645309OtherTHEA BOWMAN COMMUNITY HEALTH CENTER
MI4763959Medicaid
MIE49524Medicare UPIN