Provider Demographics
NPI:1851772917
Name:BEACH, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BEACH
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:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:8865 W 400 N STE 155
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-9010
Practice Address - Country:US
Practice Address - Phone:219-872-5655
Practice Address - Fax:219-872-2712
Is Sole Proprietor?:No
Enumeration Date:2015-06-15
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71005574A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000953975OtherBCBS BMG VASCULAR
IN201307050Medicaid
INP01743678OtherRR MEDICARE
IN201307050Medicaid