Healthcare Provider Details

I. General information

NPI: 1619945813
Provider Name (Legal Business Name): MICHAEL J BEARDMORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 12/02/2020
Certification Date: 12/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 FERRY ST
LAFAYETTE IN
47904-3055
US

IV. Provider business mailing address

1200 W WHITE RIVER BLVD
MUNCIE IN
47303-4988
US

V. Phone/Fax

Practice location:
  • Phone: 765-448-8000
  • Fax: 765-448-7611
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01038344A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: