Healthcare Provider Details

I. General information

NPI: 1346478096
Provider Name (Legal Business Name): AMIT PHULL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2009
Last Update Date: 07/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 N MICHIGAN AVE SUITE 1058 A
CHICAGO IL
60611-2826
US

IV. Provider business mailing address

259 E ERIE ST SUITE 100
CHICAGO IL
60611-2930
US

V. Phone/Fax

Practice location:
  • Phone: 312-926-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number125-056164
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: