Healthcare Provider Details

I. General information

NPI: 1528080686
Provider Name (Legal Business Name): GARY D BEAUCHAMP MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 12/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 N CHURCH RD
LIBERTY MO
64068-7129
US

IV. Provider business mailing address

5501 NW 62ND TER SUITE 201
KANSAS CITY MO
64151-2411
US

V. Phone/Fax

Practice location:
  • Phone: 816-781-1696
  • Fax: 816-781-5438
Mailing address:
  • Phone: 816-584-8884
  • Fax: 913-588-9220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberR5969
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number04-14844
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: