Provider Demographics
NPI:1992878573
Name:MONTEITH, DOUG ALAN (MD)
Entity type:Individual
Prefix:DR
First Name:DOUG
Middle Name:ALAN
Last Name:MONTEITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2740 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:#417
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
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361020502084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036102050Medicaid
ILCOMM PROVIDER #Other203712521
ILRR MEDICARE #OtherP00023316
ILBLUE SHIELD PROVIDEROther01633446
ILCOMM PROVIDER #Other203712521
ILBLUE SHIELD PROVIDEROther01633446
ILMEDICARE PINMedicare ID - Type UnspecifiedK24272
IL256510158Medicare PIN