Provider Demographics
NPI:1043494156
Name:BEACH MEDICAL GROUP PC
Entity type:Organization
Organization Name:BEACH MEDICAL GROUP PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL BILLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:TODESCA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-363-8571
Mailing Address - Street 1:1801 PLEASUREHOUSE ROAD
Mailing Address - Street 2:#105
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455
Mailing Address - Country:US
Mailing Address - Phone:757-363-8571
Mailing Address - Fax:757-363-8239
Practice Address - Street 1:1801 PLEASUREHOUSE RD
Practice Address - Street 2:#105
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455
Practice Address - Country:US
Practice Address - Phone:757-363-8571
Practice Address - Fax:757-363-8239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-26
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104001533111N00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
118947OtherANTHEM BLUE CROSS
VA6412570001Medicare NSC
VA1356412175Medicare PIN