Provider Demographics
NPI:1861657447
Name:BEVERLY, EUGENE DALE (MPA-C)
Entity Type:Individual
Prefix:MR
First Name:EUGENE
Middle Name:DALE
Last Name:BEVERLY
Suffix:
Gender:M
Credentials:MPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1584 AVALON AVE
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-9803
Mailing Address - Country:US
Mailing Address - Phone:706-860-0867
Mailing Address - Fax:
Practice Address - Street 1:300 W HOSPITAL RD
Practice Address - Street 2:CONNELLY HEALTH CLINIC
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905-5741
Practice Address - Country:US
Practice Address - Phone:706-787-5170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1025323OtherNCCPA