Provider Demographics
NPI:1285736793
Name:BEAUCHAMP, JOHN CHRISTOPHER (PT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:CHRISTOPHER
Last Name:BEAUCHAMP
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 MINORS DR
Mailing Address - Street 2:
Mailing Address - City:MUKWONAGO
Mailing Address - State:WI
Mailing Address - Zip Code:53149-9413
Mailing Address - Country:US
Mailing Address - Phone:414-640-2372
Mailing Address - Fax:262-363-5227
Practice Address - Street 1:503 MINORS DR
Practice Address - Street 2:
Practice Address - City:MUKWONAGO
Practice Address - State:WI
Practice Address - Zip Code:53149-9413
Practice Address - Country:US
Practice Address - Phone:414-640-2372
Practice Address - Fax:262-363-5227
Is Sole Proprietor?:No
Enumeration Date:2006-09-04
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIPT 5600-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI00077444470OtherAETNA ID
WI11231010OtherCAQH PROVIDER ID
WI200009840014OtherBLUE CROSS BLUE SHIELD
WI2128442OtherFIRST HEALTH ID
WI610442200OtherOWCP, US DEPT. OF LABOR
WIPT 5600-024OtherPT LICENSE
WIP00085089Medicare PIN
WI000280135Medicare PIN
WI2128442OtherFIRST HEALTH ID