Provider Demographics
NPI:1679506695
Name:BEATTY, EDDIE B (MD,MPH, SCD)
Entity Type:Individual
Prefix:
First Name:EDDIE
Middle Name:B
Last Name:BEATTY
Suffix:
Gender:M
Credentials:MD,MPH, SCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 PARSONS AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-5331
Mailing Address - Country:US
Mailing Address - Phone:614-645-7417
Mailing Address - Fax:
Practice Address - Street 1:240 PARSONS AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-5331
Practice Address - Country:US
Practice Address - Phone:614-645-7948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-05-6408-B2083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH316400223035OtherCARESOURCE CLINIC #
OH316400223040OtherCARESOURCE LAB #
OH2439749Medicaid
OHBE4121651Medicare ID - Type UnspecifiedMEDICARE #
OH2439749Medicaid