Provider Demographics
NPI:1982686358
Name:DAVIS PHILLPOTTS, BETH (MD)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:DAVIS PHILLPOTTS
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 1:9000 S STONY ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-3508
Mailing Address - Country:US
Mailing Address - Phone:773-731-0670
Mailing Address - Fax:773-731-1714
Practice Address - Street 1:675 W NORTH AVE
Practice Address - Street 2:SUITE 414
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1634
Practice Address - Country:US
Practice Address - Phone:708-681-7858
Practice Address - Fax:708-681-7816
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036089148207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036089148Medicaid
IL036089148Medicaid
ILK12655 750550Medicare ID - Type Unspecified