Healthcare Provider Details

I. General information

NPI: 1053675124
Provider Name (Legal Business Name): AMANDA DHUYVETTER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2012
Last Update Date: 04/22/2021
Certification Date: 04/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1653 W CONGRESS PKWY SUITE 720 PAVILION
CHICAGO IL
60612-3833
US

IV. Provider business mailing address

1653 W CONGRESS PKWY SUITE 720 PAVILION
CHICAGO IL
60612-3833
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-6610
  • Fax: 312-942-6606
Mailing address:
  • Phone: 312-942-6610
  • Fax: 312-942-6606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036138158
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: