Provider Demographics
NPI:1790781268
Name:BEUMER, MICHELLE L
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:BEUMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 EAST FIFTH STREET
Mailing Address - Street 2:STE 312
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090
Mailing Address - Country:US
Mailing Address - Phone:636-390-9100
Mailing Address - Fax:636-390-9109
Practice Address - Street 1:851 E 5TH ST
Practice Address - Street 2:STE 312
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-3130
Practice Address - Country:US
Practice Address - Phone:636-390-9100
Practice Address - Fax:636-390-9109
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002005319208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205840804Medicaid
MOH63952Medicare UPIN