=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083612329
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WALTER J BEUSSE DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2005
-----------------------------------------------------
Last Update Date | 05/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 824 W BARTLETT RD
-----------------------------------------------------
City | BARTLETT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60103-4402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-213-3217
-----------------------------------------------------
Fax | 630-213-8140
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7425
-----------------------------------------------------
City | ALGONQUIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60102-7425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-213-3217
-----------------------------------------------------
Fax | 630-213-8140
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 036083241
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------