Provider Demographics
NPI:1104931203
Name:BECK, PAUL RICHARD (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:RICHARD
Last Name:BECK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 COUNTRY CLUB DR
Mailing Address - Street 2:BUILDING 100, SUITE E
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-9054
Mailing Address - Country:US
Mailing Address - Phone:770-507-5000
Mailing Address - Fax:770-507-5075
Practice Address - Street 1:175 COUNTRY CLUB DR
Practice Address - Street 2:BUILDING 100, SUITE E
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-9054
Practice Address - Country:US
Practice Address - Phone:770-507-5000
Practice Address - Fax:770-507-5075
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-114125207X00000X
GA66755207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01915167OtherBLUE CROSS/BLUE SHIELD
IL035958001OtherDMERC
IL036114125Medicaid
IL109303OtherHEALTH ALLIANCE
ILI25279Medicare UPIN
ILK22032Medicare ID - Type Unspecified