Provider Demographics
NPI:1194908822
Name:SHELLY L. BETMAN, M.D. S.C.
Entity type:Organization
Organization Name:SHELLY L. BETMAN, M.D. S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BETMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-279-0599
Mailing Address - Street 1:676 N. SAINT CLAIR
Mailing Address - Street 2:SUITE 1525
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3197
Mailing Address - Country:US
Mailing Address - Phone:312-926-3470
Mailing Address - Fax:312-926-3483
Practice Address - Street 1:676 N SAINT CLAIR ST STE 1525
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2862
Practice Address - Country:US
Practice Address - Phone:312-926-3470
Practice Address - Fax:312-926-3483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36081638207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036081638Medicaid
IL036081638Medicaid
IL217085Medicare PIN