=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134144058
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD BEVERIDGE M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2006
-----------------------------------------------------
Last Update Date | 04/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 121 MEDICAL CENTER DR SUITE 3400
-----------------------------------------------------
City | BRUNSWICK
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04011-2653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-406-7300
-----------------------------------------------------
Fax | 207-406-7301
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 121 MEDICAL CENTER DR SUITE 3400
-----------------------------------------------------
City | BRUNSWICK
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04011-2653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-406-7300
-----------------------------------------------------
Fax | 207-406-7301
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 013622
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------