Healthcare Provider Details

I. General information

NPI: 1194733584
Provider Name (Legal Business Name): GEORGE THOMAS AMPALLOOR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 06/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 773-292-4501
  • Fax: 773-292-2613
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 Number036-105483
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: