Healthcare Provider Details

I. General information

NPI: 1649215211
Provider Name (Legal Business Name): BEAVERTON MEDICAL CENTER P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 07/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 W BROWN ST
BEAVERTON MI
48612-8119
US

IV. Provider business mailing address

1003 WOODSIDE AVE
ESSEXVILLE MI
48732-1234
US

V. Phone/Fax

Practice location:
  • Phone: 989-435-2937
  • Fax: 989-435-3121
Mailing address:
  • Phone: 989-892-7722
  • Fax: 989-892-7455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIAM E BERNER
Title or Position: CLINIC ADMINISTRATOR
Credential:
Phone: 989-892-7722