Provider Demographics
NPI:1962922781
Name:JENGIC, BETHANY MARY (MD)
Entity type:Individual
Prefix:MRS
First Name:BETHANY
Middle Name:MARY
Last Name:JENGIC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:BETHANY
Other - Middle Name:MARY
Other - Last Name:UNDERWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12251 S 80TH AVE STE 1630
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1256
Mailing Address - Country:US
Mailing Address - Phone:708-923-5173
Mailing Address - Fax:708-923-5018
Practice Address - Street 1:12251 S 80TH AVE
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1256
Practice Address - Country:US
Practice Address - Phone:708-923-5869
Practice Address - Fax:708-923-5859
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.152152207R00000X, 208M00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036152152Medicaid