Provider Demographics
NPI:1912968892
Name:BEACH, ANN PENDLETON (MD)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:PENDLETON
Last Name:BEACH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 N RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9251
Mailing Address - Country:US
Mailing Address - Phone:208-514-2500
Mailing Address - Fax:208-322-7018
Practice Address - Street 1:777 N RAYMOND ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9251
Practice Address - Country:US
Practice Address - Phone:208-514-2500
Practice Address - Fax:208-322-7018
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7794207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID11029901OtherMEDICARE PTAN
ID805202000Medicaid
P00031256OtherRAILROAD MEDICARE
1102998OtherCIGNA MEDICARE
1102990OtherCIGNA MEDICARE
1102990OtherCIGNA MEDICARE