Healthcare Provider Details

I. General information

NPI: 1568026276
Provider Name (Legal Business Name): JOSEPH BRENNAN DEBETTENCOURT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2019
Last Update Date: 06/28/2024
Certification Date: 06/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S PAULINA ST STE 403
CHICAGO IL
60612-3806
US

IV. Provider business mailing address

450 BROOKLINE AVE
BOSTON MA
02215-5450
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-7100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1018891
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: