Basic Information
| Provider Information | |||||||||
| NPI: | 1538241591 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | BEATY | ||||||||
| FirstName: | SHAD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19248 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627949248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175287541 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2005 JACOBSSEN DR | ||||||||
| Address2: | |||||||||
| City: | NORMAL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617616287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3093197360 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 10/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 036-106215 | IL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 036106215 | 05 | IL | MEDICAID |