Healthcare Provider Details

I. General information

NPI: 1881012474
Provider Name (Legal Business Name): KYLE T AMBER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2014
Last Update Date: 04/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3249 S. OAK PARK AVENUE
BERWYN IL
60402
US

IV. Provider business mailing address

808 S WOOD ST RM 380
CHICAGO IL
60612-7300
US

V. Phone/Fax

Practice location:
  • Phone: 708-783-3403
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number142376
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036145831
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: