Provider Demographics
NPI:1003066143
Name:BEAVERS, JOHN P (NP)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:P
Last Name:BEAVERS
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9682 DAYLILY LN
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49053-8710
Mailing Address - Country:US
Mailing Address - Phone:269-370-2669
Mailing Address - Fax:
Practice Address - Street 1:30 MARYLAND PLZ
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-1556
Practice Address - Country:US
Practice Address - Phone:314-720-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-25
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704234332207P00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1003066143Medicaid
MI500C961050OtherBCBSM
MIMI1609044Medicare PIN
MI500C961050OtherBCBSM