Provider Demographics
NPI:1790761609
Name:BECKWITH, LEE GRANGER (MD)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:GRANGER
Last Name:BECKWITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:GOOD SAMARITAN HOSPITAL
Mailing Address - Street 2:SLUCARE DEPARTMENT OF PATHOLOGY
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-4524
Mailing Address - Country:US
Mailing Address - Phone:417-556-2130
Mailing Address - Fax:417-556-2907
Practice Address - Street 1:SSMHEALTH GOOD SAMARITAN HOSPITAL
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6286
Practice Address - Country:US
Practice Address - Phone:573-450-9134
Practice Address - Fax:618-899-4720
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101537207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203381017Medicaid
OK100216240BMedicaid
MOMA3446410Medicare PIN
MO928891450Medicare ID - Type Unspecified
OK100216240BMedicaid