Provider Demographics
NPI: | 1831133768 |
---|---|
Name: | BEAVER MEDICAL GROUP, LP |
Entity Type: | Organization |
Organization Name: | BEAVER MEDICAL GROUP, LP |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | VICE PRESIDENT OF MEDICAL AFFAIRS |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | DENNIS |
Authorized Official - Middle Name: | P |
Authorized Official - Last Name: | FLYNN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 909-799-1818 |
Mailing Address - Street 1: | PO BOX 2200 |
Mailing Address - Street 2: | |
Mailing Address - City: | REDLANDS |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 92373-0722 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 909-793-3311 |
Mailing Address - Fax: | 909-796-4158 |
Practice Address - Street 1: | 2 W FERN AVE |
Practice Address - Street 2: | |
Practice Address - City: | REDLANDS |
Practice Address - State: | CA |
Practice Address - Zip Code: | 92373-5916 |
Practice Address - Country: | US |
Practice Address - Phone: | 909-793-3311 |
Practice Address - Fax: | 909-796-4158 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-06-14 |
Last Update Date: | 2020-08-22 |
Deactivation Date: | 2009-09-10 |
Deactivation Code: | |
Reactivation Date: | 2012-11-09 |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Not Answered | 152W00000X | Eye and Vision Services Providers | Optometrist | Group - Multi-Specialty | |
Not Answered | 207K00000X | Allopathic & Osteopathic Physicians | Allergy & Immunology | Group - Multi-Specialty | |
Not Answered | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
Not Answered | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
Not Answered | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
Not Answered | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Multi-Specialty |
Not Answered | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | Group - Multi-Specialty |
Not Answered | 207RR0500X | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | Group - Multi-Specialty |
Not Answered | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
Not Answered | 207W00000X | Allopathic & Osteopathic Physicians | Ophthalmology | Group - Multi-Specialty | |
Not Answered | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
Not Answered | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
Not Answered | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | Group - Multi-Specialty |
Not Answered | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
Not Answered | 208800000X | Allopathic & Osteopathic Physicians | Urology | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | ZZZ42611Z | Medicare ID - Type Unspecified |