Individual
SHAD BEATY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
2005 JACOBSSEN DR, NORMAL, IL 61761-6287
(309) 319-7360
Mailing address
PO BOX 19248, SPRINGFIELD, IL 62794-9248
(217) 528-7541
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
036-106215
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036106215
—
IL
Enumeration date
10/19/2006
Last updated
10/03/2022
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