Provider Demographics
NPI:1215996483
Name:MACINTOSH, BETTE A (MD)
Entity type:Individual
Prefix:
First Name:BETTE
Middle Name:A
Last Name:MACINTOSH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19670
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9670
Mailing Address - Country:US
Mailing Address - Phone:217-588-7717
Mailing Address - Fax:217-525-1503
Practice Address - Street 1:710 N 8TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-6324
Practice Address - Country:US
Practice Address - Phone:217-588-7717
Practice Address - Fax:217-525-1503
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360971322084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036097132Medicaid
IL343179OtherTRICARE
IL036097132Medicaid