=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568471274
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID M BEATTY MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2006
-----------------------------------------------------
Last Update Date | 12/16/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2901 OLD JACKSONVILLE RD
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62704-7437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-698-9722
-----------------------------------------------------
Fax | 217-391-0392
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 500
-----------------------------------------------------
City | CHATHAM
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62629-0500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-670-2424
-----------------------------------------------------
Fax | 217-670-2809
-----------------------------------------------------
=====================================================
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 | 38680
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 036112014
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------