Provider Demographics
NPI:1881105039
Name:BEAUMONT MEDICAL GROUP- SPECIALTY SERVICES
Entity type:Organization
Organization Name:BEAUMONT MEDICAL GROUP- SPECIALTY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. VP, BEAUMONT PHYSICIAN PARTNERS
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MANER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:947-522-1912
Mailing Address - Street 1:26901 BEAUMONT BOULEVARD
Mailing Address - Street 2:STE. 3D
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1857
Mailing Address - Fax:
Practice Address - Street 1:6900 ORCHARD LAKE RD STE 100
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3424
Practice Address - Country:US
Practice Address - Phone:248-898-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-16
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care