Provider Demographics
NPI:1962592964
Name:BEACHE, GARTH MERVID (MD)
Entity type:Individual
Prefix:DR
First Name:GARTH
Middle Name:MERVID
Last Name:BEACHE
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:PO BOX 21249
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40221-0249
Mailing Address - Country:US
Mailing Address - Phone:502-581-1500
Mailing Address - Fax:502-540-4959
Practice Address - Street 1:530 S JACKSON ST
Practice Address - Street 2:SUITE C07
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1675
Practice Address - Country:US
Practice Address - Phone:502-852-5875
Practice Address - Fax:502-852-1754
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00512942085R0204X, 2085R0202X
KY409682085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY40968OtherLICENSE
KY000000522619OtherANTHEM
IN200897990Medicaid
MDD0051294OtherLICENSE
KYP00413991OtherRAILROAD MCR
KY000000522619OtherANTHEM
MDG36166Medicare UPIN