Provider Demographics
NPI:1376616961
Name:DOUG MONTEITH M.D., S.C. INC
Entity Type:Organization
Organization Name:DOUG MONTEITH M.D., S.C. INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:MONTEITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-907-3060
Mailing Address - Street 1:2740 W FOSTER AVE
Mailing Address - Street 2:#417
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3500
Mailing Address - Country:US
Mailing Address - Phone:773-907-3060
Mailing Address - Fax:773-907-3061
Practice Address - Street 1:2740 W FOSTER AVE
Practice Address - Street 2:#401
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3500
Practice Address - Country:US
Practice Address - Phone:773-907-3060
Practice Address - Fax:773-907-3061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01633446OtherBLUE SHIELD PROVIDER #
ILP00023316OtherRR MEDICARE PROVIDER #
ILP00023316OtherRR MEDICARE PROVIDER #
IL212854Medicare ID - Type UnspecifiedMEDICARE GROUP
IL=========OtherCOMM PPO HMO PROVIDER #
ILP00023316OtherRR MEDICARE PROVIDER #