Provider Demographics
NPI:1144495193
Name:DALE W. BEAUMONT, M.D., P.C.
Entity type:Organization
Organization Name:DALE W. BEAUMONT, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:W
Authorized Official - Last Name:BEAUMONT
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:586-286-7670
Mailing Address - Street 1:42633 GARFIELD RD STE 318
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-5033
Mailing Address - Country:US
Mailing Address - Phone:586-286-7670
Mailing Address - Fax:586-286-5179
Practice Address - Street 1:42633 GARFIELD RD STE 318
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-5033
Practice Address - Country:US
Practice Address - Phone:586-286-7670
Practice Address - Fax:586-286-5179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301034186207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2132199Medicaid
MIB44670Medicare UPIN
MI0504232Medicare PIN