=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639154768
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROGER BEAUDOING DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2005
-----------------------------------------------------
Last Update Date | 02/09/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 703 N MCEWAN ST
-----------------------------------------------------
City | CLARE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48617-1440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-386-5120
-----------------------------------------------------
Fax | 989-802-8880
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5392 MANGUS
-----------------------------------------------------
City | BEAVERTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-435-4669
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 5101011345
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 5101011345
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------