MEDICARE: DR. CAMILLE MERCEDES GARDNER-BEASLEY M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	200700182	NC
2	207Q00000X	Family Medicine Physician	MEDS7564	AK
3	207Q00000X	Family Medicine Physician	7564	AK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548246085
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CAMILLE MERCEDES GARDNER-BEASLEY M.D.

Provider Business Mailing Address
First Line	:	10444 LONGMIRE RD
Second Line	:
City	:	JOINT BASE LEWIS MCCHORD
State	:	WA
Zip	:	98433-1357
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9040A JACKSON AVE
Second Line	:
City	:	JOINT BASE LEWIS MCCHORD
State	:	WA
Zip	:	98431-0001
Country	:	US
Telephone Number	:	253-968-1110
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/16/2005
Last Update Date	:	04/02/2019

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