Healthcare Provider Details

I. General information

NPI: 1699139493
Provider Name (Legal Business Name): MARY S VAMENTA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEFANIE VAMENTA YANG

II. Dates (important events)

Enumeration Date: 04/07/2016
Last Update Date: 07/08/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 S WOOD ST
CHICAGO IL
60612-4325
US

IV. Provider business mailing address

830 S WOOD ST
CHICAGO IL
60612-4325
US

V. Phone/Fax

Practice location:
  • Phone: 312-413-8898
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number36559
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036-165692
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: