Provider Demographics
NPI:1457372179
Name:BEAVER MEDICAL GROUP, LP
Entity Type:Organization
Organization Name:BEAVER MEDICAL GROUP, LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF MEDICAL AFFAIRS
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:P
Authorized Official - Last Name:FLYNN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-845-0313
Mailing Address - Street 1:PO BOX 2200
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-0722
Mailing Address - Country:US
Mailing Address - Phone:909-793-3311
Mailing Address - Fax:909-796-4158
Practice Address - Street 1:5957 W RAMSEY ST
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-3058
Practice Address - Country:US
Practice Address - Phone:951-845-0313
Practice Address - Fax:909-796-4158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2020-08-22
Deactivation Date:2009-09-10
Deactivation Code:
Reactivation Date:2012-11-09
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty