MEDICARE: BETH L TUMILTY DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RC0000X	Cardiovascular Disease Physician		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0533210001	OTHER	IL	DMERC
2	05732097	OTHER	IL	BC GROUP NUMBER
3	108541	OTHER	IL	HEALTH ALLIANCE

General Provider Information

NPI Number	:	1033159959
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BETH L TUMILTY DO

Provider Business Mailing Address
First Line	:	1302 FRANKLIN AVE
Second Line	:	#4500
City	:	NORMAL
State	:	IL
Zip	:	61761-3551
Country	:	US
Telephone Number	:	309-828-1166
Fax Number	:	309-862-0330

Provider Business Practice Location Address
First Line	:	1302 FRANKLIN AVE
Second Line	:	#4500
City	:	NORMAL
State	:	IL
Zip	:	61761-3551
Country	:	US
Telephone Number	:	309-828-1166
Fax Number	:	309-862-0330

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2006
Last Update Date	:	12/11/2007

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