Provider Demographics
NPI:1922054550
Name:BRAAK, BEVERLY L (MD)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:L
Last Name:BRAAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2831 FORT MISSOULA RD
Mailing Address - Street 2:203
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-7419
Mailing Address - Country:US
Mailing Address - Phone:406-327-3875
Mailing Address - Fax:406-327-3876
Practice Address - Street 1:2835 FORT MISSOULA RD
Practice Address - Street 2:203
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-7423
Practice Address - Country:US
Practice Address - Phone:406-327-3875
Practice Address - Fax:406-327-3876
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MT11310207V00000X
WI33235207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31851000Medicaid
F37494Medicare UPIN
WI31851000Medicaid