Provider Demographics
NPI:1689778714
Name:BEACON MEDICAL GROUP, P.A.
Entity Type:Organization
Organization Name:BEACON MEDICAL GROUP, P.A.
Other - Org Name:LONGNECK FAMILY PRACTICE, PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:E
Authorized Official - Last Name:HAWTOF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:320-947-9767
Mailing Address - Street 1:26744 JOHN J WILLIAMS HWY
Mailing Address - Street 2:OAK ORCHARD PROF SUITES #3
Mailing Address - City:MILLSBORO
Mailing Address - State:DE
Mailing Address - Zip Code:19966-4645
Mailing Address - Country:US
Mailing Address - Phone:302-947-9767
Mailing Address - Fax:302-947-9558
Practice Address - Street 1:26744 JOHN J WILLIAMS HWY
Practice Address - Street 2:OAK ORCHARD PROF SUITES #3
Practice Address - City:MILLSBORO
Practice Address - State:DE
Practice Address - Zip Code:19966-4667
Practice Address - Country:US
Practice Address - Phone:302-947-9767
Practice Address - Fax:302-947-9558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-11
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0001150402Medicaid
G00693Medicare ID - Type Unspecified