Healthcare Provider Details

I. General information

NPI: 1902803703
Provider Name (Legal Business Name): BEAVERTOWN CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 02/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3017 WILMINGTON PIKE
KETTERING OH
45429-4169
US

IV. Provider business mailing address

3017 WILMINGTON PIKE
KETTERING OH
45429-4169
US

V. Phone/Fax

Practice location:
  • Phone: 937-294-2555
  • Fax: 937-294-3211
Mailing address:
  • Phone: 937-294-2555
  • Fax: 937-294-3211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35058825R
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35052219R
License Number StateOH

VIII. Authorized Official

Name: DR. BERNARD J ROSE
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 937-294-2555