NPIMap

Organization Active NPI

Beaver Medical Group P C

Doing business as Optum Banner Specialty Care

  • Internal Medicine Physician
  • Banning, CA
National Provider Identifier
1619914959
Registry record updated Apr 14, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
BEAVER MEDICAL GROUP P C
Doing business as
Optum Banner Specialty Care
Practice address
6109 W Ramsey St
Banning, CA 92220-3051
Phone
(951) 845-0313
Fax
(909) 796-4158
NPI assigned
Jun 2, 2006
Reactivated
Nov 9, 2012
Last updated
Apr 14, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 14, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Emily Castillo
Title
Associate Director
Phone
(702) 480-2550

Specialties & licenses 12

Specialty (taxonomy)CodeLicenseStatePrimary
Optometrist 152W00000X NU
Emergency Medicine Physician 207P00000X NU
Family Medicine Physician 207Q00000X NU
Internal Medicine Physician 207R00000X NU Primary
Cardiovascular Disease Physician 207RC0000X NU
Pulmonary Disease Physician 207RP1001X NU
Medical Oncology Physician 207RX0202X NU
Obstetrics & Gynecology Physician 207V00000X NU
Ophthalmology Physician 207W00000X NU
Pediatrics Physician 208000000X NU
Surgery Physician 208600000X NU
Urology Physician 208800000X NU

Addresses

Primary practice location

6109 W Ramsey St
Banning, CA 92220-3051

Mailing address

PO Box 35380
Las Vegas, NV 89133-5380
Phone (702) 579-3209

Other names 1

  • Optum Banner Specialty Care Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031124000449 CA Part B Supplier - Clinic/Group Practice 0547164295 Receives reassigned benefits from 688 practitioners
6 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Vista, CA; Yucaipa, CA; San Bernardino, CA; Redlands, CA; Banning, CA; Beaumont, CA; Carlsbad, CA; Colton, CA…
O20121212000347 CA DME Supplier - Physician - Optometrist 0547164295 Practice locations: Banning, CA

Other NPIs with the same Medicare PAC ID 7

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 6

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1149206400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1744588800000",
    "number": "1619914959",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 35380",
            "city": "LAS VEGAS",
            "state": "NV",
            "postal_code": "891335380",
            "telephone_number": "702-579-3209"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6109 W RAMSEY ST",
            "city": "BANNING",
            "state": "CA",
            "postal_code": "922203051",
            "telephone_number": "951-845-0313",
            "fax_number": "909-796-4158"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BEAVER MEDICAL GROUP P C",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-02",
        "last_updated": "2025-04-14",
        "certification_date": "2025-04-14",
        "deactivation_date": "2009-09-10",
        "reactivation_date": "2012-11-09",
        "status": "A",
        "authorized_official_last_name": "CASTILLO",
        "authorized_official_first_name": "EMILY",
        "authorized_official_title_or_position": "ASSOCIATE DIRECTOR",
        "authorized_official_telephone_number": "702-480-2550"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "",
            "desc": "Optometrist",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207P00000X",
            "taxonomy_group": "",
            "desc": "Emergency Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "207RC0000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Cardiovascular Disease",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207RP1001X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Pulmonary Disease",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207RX0202X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Medical Oncology",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207V00000X",
            "taxonomy_group": "",
            "desc": "Obstetrics & Gynecology",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207W00000X",
            "taxonomy_group": "",
            "desc": "Ophthalmology",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "208600000X",
            "taxonomy_group": "",
            "desc": "Surgery",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "208800000X",
            "taxonomy_group": "",
            "desc": "Urology",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Optum Banner Specialty Care",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Banning, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 14, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.