Provider Demographics
NPI:1902803703
Name:BEAVERTOWN CLINIC INC
Entity Type:Organization
Organization Name:BEAVERTOWN CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-294-2555
Mailing Address - Street 1:3017 WILMINGTON PIKE
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-4169
Mailing Address - Country:US
Mailing Address - Phone:937-294-2555
Mailing Address - Fax:937-294-3211
Practice Address - Street 1:3017 WILMINGTON PIKE
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-4169
Practice Address - Country:US
Practice Address - Phone:937-294-2555
Practice Address - Fax:937-294-3211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35052219R207Q00000X
OH35058825R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHR00609981Medicaid
OHE97912Medicare UPIN
OHA17231Medicare UPIN
OHR00698961Medicare ID - Type UnspecifiedDR K ROSE INDIVIDUAL PI
OHBE9266611Medicare ID - Type UnspecifiedGROUP ID