Provider Demographics
NPI:1942219878
Name:BEACH, MICHAEL J (FNP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:BEACH
Suffix:
Gender:M
Credentials:FNP
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 1690
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46352-1690
Mailing Address - Country:US
Mailing Address - Phone:219-326-2312
Mailing Address - Fax:219-326-2584
Practice Address - Street 1:7002 W JOHNSON RD
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-8289
Practice Address - Country:US
Practice Address - Phone:219-325-0604
Practice Address - Fax:219-879-1401
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000746A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000792654OtherANTHEM BCBS
IN200233470Medicaid
IN200233470Medicaid
IN489140CMedicare PIN
IN151020008Medicare PIN