Provider Demographics
NPI:1457388944
Name:BEVERLY, ROSALIE BARATH (MD)
Entity Type:Individual
Prefix:DR
First Name:ROSALIE
Middle Name:BARATH
Last Name:BEVERLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:823 GATEWAY CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4541
Mailing Address - Country:US
Mailing Address - Phone:619-515-2300
Mailing Address - Fax:619-269-0674
Practice Address - Street 1:50 N PROGRESS DR
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-2666
Practice Address - Country:US
Practice Address - Phone:937-562-2280
Practice Address - Fax:937-562-2282
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA216029207R00000X
CAG152877207R00000X
OH35057715B207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0075835Medicaid
MA2007215Medicaid
MAA35369Medicare PIN
E86953Medicare UPIN
OH0075835Medicaid