Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111NN0400X | Neurology | 038013267 | IL |
NPI | 1639644222 |
---|---|
Provider Name | Dr. Beau Blakeley |
First Address | La Grange, IL 60525-2363 |
Second Address | La Grange, IL 60525-2363 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/10/2018 |
Last Update Date | 10/10/2018 |