Healthcare Provider Details

I. General information

NPI: 1770937161
Provider Name (Legal Business Name): THEODORA VAMVOURIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2016
Last Update Date: 10/28/2021
Certification Date: 10/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

676 N SAINT CLAIR ST STE 600
CHICAGO IL
60611-2981
US

IV. Provider business mailing address

676 N SAINT CLAIR ST STE 600
CHICAGO IL
60611-2981
US

V. Phone/Fax

Practice location:
  • Phone: 312-664-3278
  • Fax: 312-695-0063
Mailing address:
  • Phone: 312-664-3278
  • Fax: 312-695-0063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number63646
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036157462
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: