Provider Demographics
NPI:1043308828
Name:DECK, BEVERLY L (MD)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:L
Last Name:DECK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7318 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60130-3100
Mailing Address - Country:US
Mailing Address - Phone:708-560-1960
Mailing Address - Fax:
Practice Address - Street 1:7318 MADISON ST
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:IL
Practice Address - Zip Code:60130-3100
Practice Address - Country:US
Practice Address - Phone:708-560-1960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036087476208D00000X, 2083P0901X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001636851OtherBLUE CROSS/ BLUE SHIELD
IL036087476Medicaid
IL036087476Medicaid