Basic Information
| Provider Information | |||||||||
| NPI: | 1457388944 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEVERLY | ||||||||
| FirstName: | ROSALIE | ||||||||
| MiddleName: | BARATH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 823 GATEWAY CENTER WAY | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921024541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195152300 | ||||||||
| FaxNumber: | 6192690674 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 N PROGRESS DR | ||||||||
| Address2: | |||||||||
| City: | XENIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453852666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9375622280 | ||||||||
| FaxNumber: | 9375622282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 12/03/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 216029 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | G152877 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 35057715B | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0075835 | 05 | OH | MEDICAID | 2007215 | 05 | MA | MEDICAID |