Healthcare Provider Details

I. General information

NPI: 1477540938
Provider Name (Legal Business Name): CONSTANCE BECKOM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 01/08/2021
Certification Date: 01/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 E 4TH AVE
RANSON WV
25438-1617
US

IV. Provider business mailing address

203 E 4TH AVE
RANSON WV
25438-1617
US

V. Phone/Fax

Practice location:
  • Phone: 304-725-6343
  • Fax: 304-725-5523
Mailing address:
  • Phone: 304-725-6343
  • Fax: 304-725-5523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number14590
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number26847
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: