Healthcare Provider Details

I. General information

NPI: 1306198247
Provider Name (Legal Business Name): CERMAK CHILDREN'S CLINIC, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2012
Last Update Date: 10/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6917 W CERMAK ROAD
BERWYN IL
60804-2172
US

IV. Provider business mailing address

1044 N MOZART ST STE - 402
CHICAGO IL
60622-2789
US

V. Phone/Fax

Practice location:
  • Phone: 708-788-4933
  • Fax: 708-788-5296
Mailing address:
  • Phone: 773-292-4501
  • Fax: 773-292-2613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036105483
License Number StateIL

VIII. Authorized Official

Name: DR. GEORGE THOMAS AMPALLOOR
Title or Position: PRESIDENT
Credential: M.D.
Phone: 847-840-9714