Provider Demographics
NPI:1336179506
Name:BEAN, BARRY (DPM)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:
Last Name:BEAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21721 W 11 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-3717
Mailing Address - Country:US
Mailing Address - Phone:248-355-4888
Mailing Address - Fax:313-355-2565
Practice Address - Street 1:21721 W 11 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-3717
Practice Address - Country:US
Practice Address - Phone:248-355-4888
Practice Address - Fax:313-355-2565
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBB000712213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4856318250OtherBCBSM
MI1507818Medicaid
MI1507818Medicaid
MI9825457Medicare PIN
MI5635457Medicare PIN