Provider Demographics
NPI:1790742211
Name:BEARD, KRISTINE LAUREN (DO)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:LAUREN
Last Name:BEARD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:LAUREN
Other - Last Name:MIRON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:1500 E MEDICAL CENTER DRIVE
Mailing Address - Street 2:UH SOUTH F6245
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48109
Mailing Address - Country:US
Mailing Address - Phone:734-615-0199
Mailing Address - Fax:
Practice Address - Street 1:1500 E MEDICAL CENTER DRIVE
Practice Address - Street 2:UH SOUTH F6245
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109
Practice Address - Country:US
Practice Address - Phone:734-615-0199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51510139102084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00032307OtherRR MEDICARE
MIP91315Medicare UPIN
MIM12270040Medicare ID - Type UnspecifiedWA FOOTE MEMORIAL