Provider Demographics
NPI:1083612329
Name:BEUSSE, WALTER J (DO)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:J
Last Name:BEUSSE
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:PO BOX 7425
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-7425
Mailing Address - Country:US
Mailing Address - Phone:630-213-3217
Mailing Address - Fax:630-213-8140
Practice Address - Street 1:824 W BARTLETT RD
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:IL
Practice Address - Zip Code:60103-4402
Practice Address - Country:US
Practice Address - Phone:630-213-3217
Practice Address - Fax:630-213-8140
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-11
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036083241207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036083241Medicaid
IL05623130OtherBLUE CROSS BLUE SHIELD
IL05623130OtherBLUE CROSS BLUE SHIELD
ILE85300Medicare UPIN
IL989490Medicare PIN
IL989450Medicare PIN