MEDICARE: KEVIN BETHKE M.D.

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	208600000X	Surgery Physician		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01621690	OTHER	IL	BLUE SHIELD

General Provider Information

NPI Number	:	1356338883
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN BETHKE M.D.

Provider Business Mailing Address
First Line	:	PO BOX 388320
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60638-8320
Country	:	US
Telephone Number	:	773-767-8283
Fax Number	:	773-767-8320

Provider Business Practice Location Address
First Line	:	676 N SAINT CLAIR ST
Second Line	:	SUITE 1525A
City	:	CHICAGO
State	:	IL
Zip	:	60611-2927
Country	:	US
Telephone Number	:	312-943-2746
Fax Number	:	312-266-1411

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

Provider Enumeration Date	:	09/30/2005
Last Update Date	:	07/08/2007

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Directions to “ KEVIN BETHKE M.D.” Practice Location

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