Provider Demographics
NPI:1669617445
Name:MARY K. BEARD MD
Entity type:Organization
Organization Name:MARY K. BEARD MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:K
Authorized Official - Last Name:BEARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-355-9951
Mailing Address - Street 1:455 EAST SOUTH TEMPLE
Mailing Address - Street 2:#202
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111
Mailing Address - Country:US
Mailing Address - Phone:801-355-9951
Mailing Address - Fax:801-355-9968
Practice Address - Street 1:455 EAST SOUTH TEMPLE
Practice Address - Street 2:#202
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111
Practice Address - Country:US
Practice Address - Phone:801-355-9951
Practice Address - Fax:801-355-9968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-09
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT156053-1205207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT576-54-2779-043Medicaid
UT576-54-2779-043Medicaid
000002208Medicare PIN