Provider Demographics
NPI:1669434148
Name:BEACH, CHARLES JEFFREY (PA)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:JEFFREY
Last Name:BEACH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2000 FRONTIS PLAZA BLVD STE 200
Mailing Address - Street 2:ATTN FORSYTH MEDICAL GROUP
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-5616
Mailing Address - Country:US
Mailing Address - Phone:336-277-2436
Mailing Address - Fax:
Practice Address - Street 1:140 KIMEL PARK DR
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6946
Practice Address - Country:US
Practice Address - Phone:336-245-2100
Practice Address - Fax:336-765-6135
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC100198363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2753103Medicare ID - Type Unspecified