Healthcare Provider Details

I. General information

NPI: 1992703227
Provider Name (Legal Business Name): JOANNA E BETANCOURT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JOANNA E VASQUEZ MD

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 04/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S RANDALL RD SUITE 220
ALGONQUIN IL
60102-5935
US

IV. Provider business mailing address

600 S RANDALL RD SUITE 220
ALGONQUIN IL
60102-5935
US

V. Phone/Fax

Practice location:
  • Phone: 847-854-9402
  • Fax: 847-854-9403
Mailing address:
  • Phone: 847-854-9402
  • Fax: 847-854-9403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036101829
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier036101829
Identifier TypeMEDICAID
Identifier StateIL
Identifier Issuer
# 2
Identifier05632081
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerBLUE CROSS BLUE SHIELD
# 3
Identifier07100058
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerIL HEALTH CONNECT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: