Provider Demographics
NPI:1124242243
Name:DEVANEY, ELIZABETH J (MD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:J
Last Name:DEVANEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:VANDEVELDE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:7005 JOHNSBURG RD
Mailing Address - Street 2:
Mailing Address - City:SPRING GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60081-9365
Mailing Address - Country:US
Mailing Address - Phone:815-675-6622
Mailing Address - Fax:815-675-0044
Practice Address - Street 1:7005 JOHNSBURG RD
Practice Address - Street 2:
Practice Address - City:SPRING GROVE
Practice Address - State:IL
Practice Address - Zip Code:60081-9365
Practice Address - Country:US
Practice Address - Phone:815-675-6622
Practice Address - Fax:815-675-0044
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32277207Q00000X
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31749600Medicaid
WI31749600Medicaid