Basic Information
| Provider Information | |||||||||
| NPI: | 1992777908 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BEAUMONT | ||||||||
| FirstName: | EDGAR | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MICHIGAN ST NE | ||||||||
| Address2: | MC845 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164866790 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 MICHIGAN ST NE | ||||||||
| Address2: | FLOOR 3W, MC 035 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163911714 | ||||||||
| FaxNumber: | 6163911332 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2006 | ||||||||
| LastUpdateDate: | 03/23/2015 | ||||||||
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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 | 2080N0001X | 4301043781 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3504101941 | 01 | MI | BCBS | OTHER | 1558407189 | 01 | MI | GROUP NPI | OTHER | 6067123 | 05 | MI | MEDICAID |