Provider Demographics
NPI:1912180134
Name:BEVERIDGE MEDICAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:BEVERIDGE MEDICAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:D
Authorized Official - Last Name:BEVERIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-774-0478
Mailing Address - Street 1:818 SAINT SEBASTIAN WAY
Mailing Address - Street 2:SUITE 408
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2651
Mailing Address - Country:US
Mailing Address - Phone:706-774-0478
Mailing Address - Fax:706-774-0876
Practice Address - Street 1:818 SAINT SEBASTIAN WAY
Practice Address - Street 2:SUITE 408
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2651
Practice Address - Country:US
Practice Address - Phone:706-774-0478
Practice Address - Fax:706-774-0876
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAYNE D. BEVERIDGE, MD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-11
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA020405207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D28918Medicare UPIN
GA6655Medicare PIN