Provider Demographics
NPI:1306281480
Name:BEALLY, MELISSA (MD)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:BEALLY
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 1:1430 TULANE AVE
Mailing Address - Street 2:SL-11
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70112-2632
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 ERIE CT STE 6040
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2510
Practice Address - Country:US
Practice Address - Phone:708-386-1301
Practice Address - Fax:708-386-3053
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-02
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA390200000X
IL036143475207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program