Provider Demographics
NPI:1922064401
Name:BEACH, ANITA L (NP)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:L
Last Name:BEACH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 BAKER AVE
Mailing Address - Street 2:GLACIER MEDICAL ASSOCIATES
Mailing Address - City:WHITEFISH
Mailing Address - State:MT
Mailing Address - Zip Code:59937-2901
Mailing Address - Country:US
Mailing Address - Phone:406-862-2515
Mailing Address - Fax:406-862-4229
Practice Address - Street 1:1111 BAKER AVE
Practice Address - Street 2:GLACIER MEDICAL ASSOCIATES
Practice Address - City:WHITEFISH
Practice Address - State:MT
Practice Address - Zip Code:59937-2901
Practice Address - Country:US
Practice Address - Phone:406-862-2515
Practice Address - Fax:406-862-4229
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTRN024700207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTRN024700OtherMONTANA STATE LICENSE
MT500004073OtherRAILROAD MEDICARE PIN#
MT27D0411341OtherCLIA ID#---LAB CERT
MT0432157Medicaid
MT1104882232OtherGLACIER MEDICAL ASSOC NPI
NVCI2709OtherRAILROAD MEDICARE GRP ID#
MT000037436OtherBLUE CORSS/SHIELD PIN
MT810350909OtherFEIN
MT000008287OtherMEDICARE PART B GRP ID#
NVCI2709OtherRAILROAD MEDICARE GRP ID#
MT810350909OtherFEIN
MT000037436OtherBLUE CORSS/SHIELD PIN