MEDICARE: DR. GEORGE THOMAS AMPALLOOR MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	036-105483	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194733584
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GEORGE THOMAS AMPALLOOR MD

Provider Business Mailing Address
First Line	:	1044 N MOZART ST
Second Line	:	SUITE 402
City	:	CHICAGO
State	:	IL
Zip	:	60622-2789
Country	:	US
Telephone Number	:	773-292-4501
Fax Number	:	773-292-2613

Provider Business Practice Location Address
First Line	:	1044 N MOZART ST
Second Line	:	SUITE 402
City	:	CHICAGO
State	:	IL
Zip	:	60622-2789
Country	:	US
Telephone Number	:	773-292-4501
Fax Number	:	773-292-2613

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2006
Last Update Date	:	06/15/2016

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