Provider Demographics
NPI:1154523504
Name:HIRSCH, BETH F
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:F
Last Name:HIRSCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 FORD AVE
Mailing Address - Street 2:
Mailing Address - City:HOPEDALE
Mailing Address - State:IL
Mailing Address - Zip Code:61747-9485
Mailing Address - Country:US
Mailing Address - Phone:309-449-3336
Mailing Address - Fax:309-449-6001
Practice Address - Street 1:143 FORD AVE
Practice Address - Street 2:
Practice Address - City:HOPEDALE
Practice Address - State:IL
Practice Address - Zip Code:61747-9485
Practice Address - Country:US
Practice Address - Phone:309-449-3336
Practice Address - Fax:309-449-6001
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL04-189487363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCA4079OtherRR GROUP
ILP00414346OtherRR INDIVIDUAL
ILP00414346OtherRR INDIVIDUAL
IL809840Medicare ID - Type UnspecifiedGROUP #