Basic Information
| Provider Information | |||||||||
| NPI: | 1770877672 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BEATTIE | ||||||||
| FirstName: | ADAM | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 77 N AIRLITE ST | ||||||||
| Address2: | |||||||||
| City: | ELGIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601234912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476953200 | ||||||||
| FaxNumber: | 8479315778 | ||||||||
| Practice Location | |||||||||
| Address1: | 3999 RICHMOND RD | ||||||||
| Address2: | |||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441226046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2165931495 | ||||||||
| FaxNumber: | 2162015293 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2011 | ||||||||
| LastUpdateDate: | 11/13/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 036134860 | IL | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 35.134365 | OH | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 036134860 | 05 | IL | MEDICAID |