Provider Demographics
NPI:1043278484
Name:BEASLEY, BRENT W (MD)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:W
Last Name:BEASLEY
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 740019
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-0019
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:
Practice Address - Street 1:16659 E 23RD ST S
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-1922
Practice Address - Country:US
Practice Address - Phone:816-688-6000
Practice Address - Fax:816-631-1885
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000163858207RG0300X
OK18452207R00000X
KS0426982207RG0300X
MO2023008158207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0401810OtherUNITED HEALTHCARE
MO200189777OtherHUMANA
MO186249OtherCOVENTRY
MO5612302005OtherCIGNA
MO27634041OtherBLUE CROSS BLUE SHIELD
MO5682498OtherAETNA
G06922Medicare UPIN
MO5682498OtherAETNA
MO27634041OtherBLUE CROSS BLUE SHIELD
MOP87A720Medicare ID - Type Unspecified