Healthcare Provider Details

I. General information

NPI: 1639154768
Provider Name (Legal Business Name): ROGER BEAUDOING DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 02/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 N MCEWAN ST
CLARE MI
48617-1440
US

IV. Provider business mailing address

5392 MANGUS
BEAVERTON MI
48612
US

V. Phone/Fax

Practice location:
  • Phone: 989-386-5120
  • Fax: 989-802-8880
Mailing address:
  • Phone: 989-435-4669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101011345
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5101011345
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: