Healthcare Provider Details

I. General information

NPI: 1114057080
Provider Name (Legal Business Name): JACQUES D. BEVERIDGE MD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 10/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1460 MAIN ST SUITE B
LANDER WY
82520-2657
US

IV. Provider business mailing address

1460 MAIN ST SUITE B
LANDER WY
82520-2657
US

V. Phone/Fax

Practice location:
  • Phone: 307-332-2223
  • Fax:
Mailing address:
  • Phone: 307-332-2223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number6275A
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number8746.0044
License Number StateWY

VIII. Authorized Official

Name: MR. FREDERICK J ZEBROSKI
Title or Position: MANAGER
Credential:
Phone: 307-332-2223