Healthcare Provider Details

I. General information

NPI: 1619377454
Provider Name (Legal Business Name): BEAUMONT INTEGRATED MEDICINE PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2014
Last Update Date: 09/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

989 GOVERNORS LN
LEXINGTON KY
40513-1173
US

IV. Provider business mailing address

7980 SOLUTION CTR
CHICAGO IL
60677-7009
US

V. Phone/Fax

Practice location:
  • Phone: 859-559-4272
  • Fax:
Mailing address:
  • Phone: 859-559-4272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number36483
License Number StateKY

VIII. Authorized Official

Name: MR. DANIEL VANHOOSE
Title or Position: ADMINISTRATOR
Credential: ARNP
Phone: 859-559-0804