1992703227 NPI number — JOANNA E BETANCOURT MD

Table of content: JOANNA E BETANCOURT MD (NPI 1992703227)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992703227 NPI number — JOANNA E BETANCOURT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BETANCOURT
Provider First Name:
JOANNA
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VASQUEZ
Provider Other First Name:
JOANNA
Provider Other Middle Name:
E
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1992703227
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 S RANDALL RD
Provider Second Line Business Mailing Address:
SUITE 220
Provider Business Mailing Address City Name:
ALGONQUIN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60102-5935
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-854-9402
Provider Business Mailing Address Fax Number:
847-854-9403

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 S RANDALL RD
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
ALGONQUIN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60102-5935
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-854-9402
Provider Business Practice Location Address Fax Number:
847-854-9403
Provider Enumeration Date:
07/11/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  036101829 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036101829 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05632081 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 07100058 . This is a "IL HEALTH CONNECT" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com