Provider Demographics
NPI:1992777908
Name:BEAUMONT, EDGAR J (MD)
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:J
Last Name:BEAUMONT
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-486-6790
Mailing Address - Fax:
Practice Address - Street 1:100 MICHIGAN ST NE
Practice Address - Street 2:FLOOR 3W, MC 035
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2560
Practice Address - Country:US
Practice Address - Phone:616-391-1714
Practice Address - Fax:616-391-1332
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI43010437812080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3504101941OtherBCBS
MI1558407189OtherGROUP NPI
MI6067123Medicaid
MI1558407189OtherGROUP NPI