MEDICARE: MR. BENJAMIN F BEAUMONT P.A.

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	363AS0400X	Surgical Physician Assistant	118266	MO
2	363A00000X	Physician Assistant	3997-23	WI

General Provider Information

NPI Number	:	1477651743
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BENJAMIN F BEAUMONT P.A.

Provider Business Mailing Address
First Line	:	34700 VALLEY RD
Second Line	:
City	:	OCONOMOWOC
State	:	WI
Zip	:	53066-4500
Country	:	US
Telephone Number	:	800-767-4411
Fax Number	:	262-646-3158

Provider Business Practice Location Address
First Line	:	4600 W SCHROEDER DR
Second Line	:
City	:	BROWN DEER
State	:	WI
Zip	:	53223-1469
Country	:	US
Telephone Number	:	800-767-4411
Fax Number	:	414-797-0804

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

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	11/13/2017

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