MEDICARE: BRUCE BEAVERS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207X00000X	Orthopaedic Surgery Physician	G3143	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	889161	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1215914817
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRUCE BEAVERS M.D.

Provider Business Mailing Address
First Line	:	PO BOX 678333
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75267-8333
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8220 WALNUT HILL LN
Second Line	:	SUITE 300
City	:	DALLAS
State	:	TX
Zip	:	75231-4427
Country	:	US
Telephone Number	:	214-265-1900
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/27/2005
Last Update Date	:	05/24/2011

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