Basic Information
| Provider Information | |||||||||
| NPI: | 1881763720 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEAUCHAMP | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | TODD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1060 GAFFNEY RD STOP 7440 | ||||||||
| Address2: | BASSETT ARMY COMMUNITY HOSPITAL (ATTN MCUC-MMD-QM) | ||||||||
| City: | FT WAINWRIGHT | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997035007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073615603 | ||||||||
| FaxNumber: | 9073614847 | ||||||||
| Practice Location | |||||||||
| Address1: | 1060 GAFFNEY RD STOP 7440 | ||||||||
| Address2: | BASSETT ARMY COMMUNITY HOSPITAL (ATTN MCUC-MMD-QM) | ||||||||
| City: | FT WAINWRIGHT | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997035007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073615603 | ||||||||
| FaxNumber: | 9073614847 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 01/14/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01055286A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.