Provider Demographics
NPI:1316920986
Name:BEATY, SEAN DALY (MD)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:DALY
Last Name:BEATY
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 1:1 INDEPENDENCE PT STE 202
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:877-406-2916
Mailing Address - Fax:
Practice Address - Street 1:4101 WAGON TRAIL AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-4426
Practice Address - Country:US
Practice Address - Phone:702-942-4123
Practice Address - Fax:702-942-4124
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV118442085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVP00342670OtherRR MEDICARE
AZ86080015085259A463OtherTRICARE WEST
NV100509912Medicaid
AZ939788Medicaid
NVCC4853OtherBLUE
NVP00342670OtherRR MEDICARE
AZ939788Medicaid
NV102599Medicare PIN