Provider Demographics
NPI:1154435550
Name:BEVILLE, ROGER W (MD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:W
Last Name:BEVILLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:460 MALL BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-4801
Mailing Address - Country:US
Mailing Address - Phone:912-644-5300
Mailing Address - Fax:912-644-3369
Practice Address - Street 1:1000 B. NORTH VETERANS BOULEVARD
Practice Address - Street 2:
Practice Address - City:GLENNVILLE
Practice Address - State:GA
Practice Address - Zip Code:30427
Practice Address - Country:US
Practice Address - Phone:912-654-4599
Practice Address - Fax:912-644-5260
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA028377207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000641946BMedicaid
GA08CBCPSOtherMEDICARE # CAHABA
GA336806OtherWELLCARE
GA000641946CMedicaid
GA08CBCPSOtherMEDICARE # CAHABA
B92324Medicare UPIN