Provider Demographics
NPI:1508188111
Name:BECKERLY, AIDA (DO)
Entity Type:Individual
Prefix:DR
First Name:AIDA
Middle Name:
Last Name:BECKERLY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 N LAKE SHORE DR
Mailing Address - Street 2:SUITE 1040
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4546
Mailing Address - Country:US
Mailing Address - Phone:773-554-6055
Mailing Address - Fax:844-258-5611
Practice Address - Street 1:680 N LAKE SHORE DR
Practice Address - Street 2:SUITE 1040
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-4546
Practice Address - Country:US
Practice Address - Phone:773-554-6055
Practice Address - Fax:844-258-5611
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-23
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY243290207Q00000X
IL036134095207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1750733788Medicare PIN