Healthcare Provider Details

I. General information

NPI: 1447240312
Provider Name (Legal Business Name): MICHAEL LELAND BEAVERS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 08/01/2025
Certification Date: 08/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1502 PEMBERTON DR UNIT D
SALISBURY MD
21801
US

IV. Provider business mailing address

8678 SPUR LN
EASTON MD
21601
US

V. Phone/Fax

Practice location:
  • Phone: 410-641-9450
  • Fax: 410-641-9515
Mailing address:
  • Phone: 410-641-9450
  • Fax: 410-641-9515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LA0401X
TaxonomyAddiction Medicine (Anesthesiology) Physician
License NumberH0057008
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: