Healthcare Provider Details

I. General information

NPI: 1477651743
Provider Name (Legal Business Name): BENJAMIN F BEAUMONT P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: CATHRYN A SALLA P.A.

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 11/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 W SCHROEDER DR
BROWN DEER WI
53223-1469
US

IV. Provider business mailing address

34700 VALLEY RD
OCONOMOWOC WI
53066-4500
US

V. Phone/Fax

Practice location:
  • Phone: 800-767-4411
  • Fax: 414-797-0804
Mailing address:
  • Phone: 800-767-4411
  • Fax: 262-646-3158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3997-23
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number118266
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: