Provider Demographics
NPI:1487768941
Name:BEATRIZ HUERTAS RIVERA MD SC
Entity type:Organization
Organization Name:BEATRIZ HUERTAS RIVERA MD SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BEATRIZ
Authorized Official - Middle Name:
Authorized Official - Last Name:HUERTAS-RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-345-8255
Mailing Address - Street 1:1419 W LAKE ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-3930
Mailing Address - Country:US
Mailing Address - Phone:708-345-8255
Mailing Address - Fax:708-345-0534
Practice Address - Street 1:1419 W LAKE ST
Practice Address - Street 2:SUITE D
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-3930
Practice Address - Country:US
Practice Address - Phone:708-345-8255
Practice Address - Fax:708-345-0534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036113545207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========OtherTAX IDENTIFICATION NUMBER