Ravenna Family Practice, P.C.
Organization Active NPI Family Medicine Physician · Ravenna, MI
NPI 1497928469 · NPPES record last updated Apr 10, 2008
Key facts
- NPI
- 1497928469
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Family Medicine Physician 207Q00000X
- License
- 008430 (MI)
- Legal business name
- RAVENNA FAMILY PRACTICE, P.C.
- Practice address
- 12520 Crockery Creek Dr.
Ravenna, MI 49451 - Phone
- (231) 853-2954
- Fax
- (231) 853-6089
- NPI assigned
- Apr 10, 2008
- Organization subpart
- No
Authorized official
- Name
- Timothy Lee Beechnau, D.O.
- Title
- Owner
- Phone
- (231) 853-2954
Practitioners 4
-
Nicholas S Beechnau, D.O.
-
Timothy L Beechnau, D.O.
-
Jonas P Berlin, DO
-
Kelley Marie Young, FNP
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 23D0704669 | Ravenna Family Practice PC | Certificate of waiver | Aug 31, 2026 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MI
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040423001167 | MI | Part B Supplier - Clinic/Group Practice | 8224023148 |
Receives reassigned benefits from 4 practitioners Practice locations: Ravenna, MI |
National Provider Directory
Locations
12520 Crockery Creek Dr
Ravenna, MI 49451
Phone (231) 853-2954
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | 008430 | MI | Yes |
Addresses
Primary practice location
12520 Crockery Creek Dr.
Ravenna, MI 49451
Mailing address
12520 Crockery Creek Dr.
Ravenna, MI 49451
Phone (231) 853-2954
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 4480790 | Medicaid | MI |
Other providers in Ravenna, MI
- Daniel Paul Meeuwsen
- Missi'S Place Counseling, PLLC
- Bonnie Jean Pline
- Kyle Stanley Pline
- Hillarey Poffinbarger
- Resfeber Therapy
- Robert D & Cindy L Douglas
- Karen Danielle Rubin-Fortier
- Emma Swanson
- Alisha Lewise Warner
All providers in Ravenna, MI · Family Medicine Physician in Michigan
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 10, 2008. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.