=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952984973
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTIAN BEAUREGARD DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2021
-----------------------------------------------------
Last Update Date | 09/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 777 HOSPITAL WAY
-----------------------------------------------------
City | POCATELLO
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83201-5175
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-239-1000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 NORTH ST APT 1R
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04101-2742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-491-6163
-----------------------------------------------------
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 | 1161576
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------