Healthcare Provider Details

I. General information

NPI: 1821345208
Provider Name (Legal Business Name): CHICAGO AMBULATORY CARE CENTER, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2012
Last Update Date: 09/11/2021
Certification Date: 09/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 773-292-4501
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036105483
License Number StateIL

VIII. Authorized Official

Name: DR. GEORGE THOMAS AMPALLOOR
Title or Position: PRESIDENT
Credential: M.D
Phone: 773-292-4501