=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104856087
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRYAN JAMES BEARDSLEY M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/04/2006
-----------------------------------------------------
Last Update Date | 06/24/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 320 WARNER DR
-----------------------------------------------------
City | LEWISTON
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83501-4441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-743-3523
-----------------------------------------------------
Fax | 208-746-8471
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 320 WARNER DR
-----------------------------------------------------
City | LEWISTON
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83501-4441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-743-3523
-----------------------------------------------------
Fax | 208-746-8471
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | M9722
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | MD00044939
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------