MEDICARE: DR. STACY ELISE BEUTE OD

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	152W00000X	Optometrist		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1633693	OTHER	IL	BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1952492647
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STACY ELISE BEUTE OD

Provider Business Mailing Address
First Line	:	1728 W ROSCOE ST APT 3E
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-1082
Country	:	US
Telephone Number	:	708-456-3232
Fax Number	:	708-456-3371

Provider Business Practice Location Address
First Line	:	7310 W NORTH AVE STE 2H
Second Line	:
City	:	ELMWOOD PARK
State	:	IL
Zip	:	60707-4212
Country	:	US
Telephone Number	:	708-456-3232
Fax Number	:	708-456-3371

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

Provider Enumeration Date	:	09/27/2006
Last Update Date	:	07/08/2007

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