Provider Demographics
NPI:1679899215
Name:GEDRICK, BEAU PHILIP (DO)
Entity type:Individual
Prefix:
First Name:BEAU
Middle Name:PHILIP
Last Name:GEDRICK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4490 WASHINGTON RD STE 2
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-5899
Mailing Address - Country:US
Mailing Address - Phone:762-930-3539
Mailing Address - Fax:706-391-4250
Practice Address - Street 1:4490 WASHINGTON RD STE 2
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-5899
Practice Address - Country:US
Practice Address - Phone:762-930-3539
Practice Address - Fax:706-391-4250
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-07
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA075463207P00000X, 207PS0010X
MI38-2947657390200000X
FLOS12484207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003173115BMedicaid
GA20293I7700Medicare PIN