Provider Demographics
NPI:1396741096
Name:BEACH, BRIAN J (DPM)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:BEACH
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 1:106 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DRY RIDGE
Mailing Address - State:KY
Mailing Address - Zip Code:41035-9406
Mailing Address - Country:US
Mailing Address - Phone:859-824-1444
Mailing Address - Fax:
Practice Address - Street 1:106 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DRY RIDGE
Practice Address - State:KY
Practice Address - Zip Code:41035-9406
Practice Address - Country:US
Practice Address - Phone:859-824-1444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2008-07-30
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
KY00254213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY80002546Medicaid
KY2016701Medicare ID - Type Unspecified
KY80002546Medicaid