Healthcare Provider Details

I. General information

NPI: 1275654006
Provider Name (Legal Business Name): AMANDA K FINGARSON D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W HARRISON ST
CHICAGO IL
60612-3714
US

IV. Provider business mailing address

130 S CANAL ST #311
CHICAGO IL
60606-3906
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-4140
  • Fax:
Mailing address:
  • Phone: 312-498-6971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-116433
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: