Basic Information
| Provider Information | |||||||||
| NPI: | 1154435550 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BEVILLE | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 460 MALL BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314064801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126445300 | ||||||||
| FaxNumber: | 9126443369 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 B. NORTH VETERANS BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | GLENNVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126544599 | ||||||||
| FaxNumber: | 9126445260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2006 | ||||||||
| LastUpdateDate: | 01/26/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 028377 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000641946B | 05 | GA | MEDICAID | 08CBCPS | 01 | GA | MEDICARE # CAHABA | OTHER | 336806 | 01 | GA | WELLCARE | OTHER | 000641946C | 05 | GA | MEDICAID |