Provider Demographics
NPI:1114064672
Name:BETMAN, SHELLY L (MD)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:L
Last Name:BETMAN
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 1:676 N SAINT CLAIR ST STE 1525
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2862
Mailing Address - Country:US
Mailing Address - Phone:312-926-3470
Mailing Address - Fax:312-926-3483
Practice Address - Street 1:676 N SAINT CLAIR ST STE 1525
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2862
Practice Address - Country:US
Practice Address - Phone:312-926-3470
Practice Address - Fax:312-926-3483
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036081638207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036081638Medicaid
ILE84661Medicare UPIN
IL036081638Medicaid