Healthcare Provider Details

I. General information

NPI: 1407811391
Provider Name (Legal Business Name): GLENN J BEAUMAN P.A.-C.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N WOLFE ST
BALTIMORE MD
21287-0005
US

IV. Provider business mailing address

PO BOX 64358
BALTIMORE MD
21264-4358
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-6500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC02310
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: