Provider Demographics
NPI:1023085693
Name:BEAN, FREDERICK L (MD)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:L
Last Name:BEAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 ENGLE DR
Mailing Address - Street 2:
Mailing Address - City:OLIVET
Mailing Address - State:MI
Mailing Address - Zip Code:49076-9603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:221 ENGLE DR
Practice Address - Street 2:
Practice Address - City:OLIVET
Practice Address - State:MI
Practice Address - Zip Code:49076-9603
Practice Address - Country:US
Practice Address - Phone:269-749-4681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301037024207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI01-02267OtherPHP
P00852222OtherMEDICARERR
MI700D410040OtherCOMMUNITY BLUE
MI700D410040OtherBLUE CROSS BLUE SHIELD
MI700D410040OtherBLUE CHOICE
MID72570Medicare UPIN
MI4855600Medicaid
M28750Medicare PIN
MI4337705OtherAETNA
MI700D410040OtherBLUE CARE NETWORK
MIOM2840034Medicare ID - Type Unspecified
MI1018173OtherMCLAREN HEALTH PLAN
MI1018173OtherMCLAREN HEALTH ADVANTAGE
MI0802315121OtherBLUE CROSS BLUE SHIELD MI
MID72570OtherHEALTH NET FEDERAL SERVIC