Provider Demographics
NPI:1528175676
Name:BEAVER, STEVEN R (MD)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:R
Last Name:BEAVER
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 1:515 S ILIFF DR
Mailing Address - Street 2:
Mailing Address - City:RENSSELAER
Mailing Address - State:IN
Mailing Address - Zip Code:47978-3242
Mailing Address - Country:US
Mailing Address - Phone:219-863-3246
Mailing Address - Fax:
Practice Address - Street 1:919 E GRACE ST
Practice Address - Street 2:
Practice Address - City:RENSSELAER
Practice Address - State:IN
Practice Address - Zip Code:47978-3207
Practice Address - Country:US
Practice Address - Phone:219-866-8971
Practice Address - Fax:219-866-4115
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01026996207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100142800Medicaid
INB28842OtherUPIN
IN000000084577OtherBLUE CROSS BLUE SHIELD
IN390640Medicare PIN