=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083619936
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIMOTHY L BEECHNAU D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2005
-----------------------------------------------------
Last Update Date | 03/08/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12520 CROCKERY CREEK DR.
-----------------------------------------------------
City | RAVENNA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-853-6725
-----------------------------------------------------
Fax | 231-853-6089
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 179
-----------------------------------------------------
City | RAVENNA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49451-0179
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-853-6725
-----------------------------------------------------
Fax | 231-853-6089
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 008430
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------