=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407183353
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL ALAN BEASLEY M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2009
-----------------------------------------------------
Last Update Date | 11/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3401 CIVIC CENTER BLVD
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19104-4319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-590-1000
-----------------------------------------------------
Fax | 267-876-2181
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3401 CIVIC CENTER BLVD
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19104-4319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-590-1000
-----------------------------------------------------
Fax | 267-876-8121
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080S0010X
-----------------------------------------------------
Taxonomy Name | Pediatric Sports Medicine Physician
-----------------------------------------------------
License Number | MD483528
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------