Basic Information
| Provider Information | |||||||||
| NPI: | 1407183353 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEASLEY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | ALAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 LONGWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021155724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173556000 | ||||||||
| FaxNumber: | 6177304712 | ||||||||
| Practice Location | |||||||||
| Address1: | 319 LONGWOOD AVE | ||||||||
| Address2: | DEPT OF SPORTS MEDICINE | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021155728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173558597 | ||||||||
| FaxNumber: | 6177304712 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2009 | ||||||||
| LastUpdateDate: | 09/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 247169 | MA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | R70720 | AZ | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080S0010X | 247169 | MA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 525196 | 05 | AZ | MEDICAID | 247169 | 01 | MA | MASSACHUSETTS LICENSE | OTHER | 900001779 | 01 | AZ | EMPLOYEE NUMBER | OTHER |