Healthcare Provider Details

I. General information

NPI: 1285736793
Provider Name (Legal Business Name): JOHN CHRISTOPHER BEAUCHAMP PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2006
Last Update Date: 04/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 MINORS DR
MUKWONAGO WI
53149-9413
US

IV. Provider business mailing address

503 MINORS DR
MUKWONAGO WI
53149-9413
US

V. Phone/Fax

Practice location:
  • Phone: 414-640-2372
  • Fax: 262-363-5227
Mailing address:
  • Phone: 414-640-2372
  • Fax: 262-363-5227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 5600-024
License Number StateWI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier00077444470
Identifier TypeOTHER
Identifier StateWI
Identifier IssuerAETNA ID
# 2
Identifier11231010
Identifier TypeOTHER
Identifier StateWI
Identifier IssuerCAQH PROVIDER ID
# 3
Identifier200009840014
Identifier TypeOTHER
Identifier StateWI
Identifier IssuerBLUE CROSS BLUE SHIELD
# 4
Identifier2128442
Identifier TypeOTHER
Identifier StateWI
Identifier IssuerFIRST HEALTH ID
# 5
Identifier610442200
Identifier TypeOTHER
Identifier StateWI
Identifier IssuerOWCP, US DEPT. OF LABOR
# 6
IdentifierPT 5600-024
Identifier TypeOTHER
Identifier StateWI
Identifier IssuerPT LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: