Healthcare Provider Details

I. General information

NPI: 1346278363
Provider Name (Legal Business Name): BEAVER MEDICAL GROUP, LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 09/25/2019
Certification Date:
Deactivation Date: 09/10/2009
Reactivation Date: 11/09/2012

III. Provider practice location address

7223 CHURCH ST STE C
HIGHLAND CA
92346-5869
US

IV. Provider business mailing address

PO BOX 10069
SAN BERNARDINO CA
92423-0069
US

V. Phone/Fax

Practice location:
  • Phone: 909-862-1191
  • Fax: 909-796-4158
Mailing address:
  • Phone: 909-335-4188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CHARLES CHEN
Title or Position: SENIOR MEDICAL DIRECTOR
Credential: M.D.
Phone: 909-793-3311