Healthcare Provider Details

I. General information

NPI: 1023039138
Provider Name (Legal Business Name): SHEBA AMPALLOOR M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 04/21/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E 51ST ST PROVIDENT HOSPITAL OF COOK COUNTY
CHICAGO IL
60615-2400
US

IV. Provider business mailing address

905 E KIMBER LN
ARLINGTON HTS IL
60005-4320
US

V. Phone/Fax

Practice location:
  • Phone: 312-572-1200
  • Fax: 312-572-1294
Mailing address:
  • Phone: 847-427-8834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036099775
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036-099775
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: