Provider Demographics
NPI:1689647935
Name:SUPERVILLE, BEATRICE A (MD)
Entity Type:Individual
Prefix:
First Name:BEATRICE
Middle Name:A
Last Name:SUPERVILLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 4TH AVE W
Mailing Address - Street 2:
Mailing Address - City:CRESCO
Mailing Address - State:IA
Mailing Address - Zip Code:52136-1449
Mailing Address - Country:US
Mailing Address - Phone:563-547-4295
Mailing Address - Fax:
Practice Address - Street 1:219 4TH AVE W
Practice Address - Street 2:
Practice Address - City:CRESCO
Practice Address - State:IA
Practice Address - Zip Code:52136-1449
Practice Address - Country:US
Practice Address - Phone:563-547-4295
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN43456207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAG43990Medicare UPIN