Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207PE0004X | Emergency Medical Services | 20243 | AL |
Y | 207Q00000X | Family Doctor | 20243 | AL |
N | 207QA0401X | Family Doctor - Addiction Medicine | 20243 | AL |
N | 207QA0505X | Family Doctor - Adult Medicine | 20243 | AL |
N | 207QG0300X | Family Doctor - Geriatric Medicine | 20243 | AL |
NPI | 1205803327 |
---|---|
Provider Name | Mr. D'livro Lemat Beauchamp |
First Address | Montgomery, AL 36106-3078 |
Second Address | Montgomery, AL 36106-3078 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/03/2006 |
Last Update Date | 11/06/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
009987015 | (05) | AL |
515-21545 | BCBS ALABAMA (01) | AL |
G40124 | (02) | AL |