Basic Information
| Provider Information | |||||||||
| NPI: | 1700832326 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VEASEY | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | ELLEN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BEVERSDORF | ||||||||
| OtherFirstName: | REBECCA | ||||||||
| OtherMiddleName: | ELLEN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1000 REMINGTON BLVD | ||||||||
| Address2: | SUITE 100 (ATTN: MELVONNE JONES) | ||||||||
| City: | BOLINGBROCK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604400000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309142417 | ||||||||
| FaxNumber: | 6309142469 | ||||||||
| Practice Location | |||||||||
| Address1: | 856 NORTH CONVENT | ||||||||
| Address2: | SUITE C | ||||||||
| City: | BOURBONNAIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609140000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159365167 | ||||||||
| FaxNumber: | 6309142469 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 01/11/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085001046 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 085.001046 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 085001046 | 05 | IL | MEDICAID | 4622394 | 01 | BCBS | OTHER |