Healthcare Provider Details

I. General information

NPI: 1740417286
Provider Name (Legal Business Name): AMANDA S LAREAU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA M SILVERIO M.D.

II. Dates (important events)

Enumeration Date: 06/11/2009
Last Update Date: 12/16/2021
Certification Date: 12/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 E CONGRESS PKWY DERICK DERMATOLOGY SUITE 200
CRYSTAL LAKE IL
60014-6245
US

IV. Provider business mailing address

525 E CONGRESS PKWY DERICK DERMATOLOGY SUITE 200
CRYSTAL LAKE IL
60014-6245
US

V. Phone/Fax

Practice location:
  • Phone: 847-381-8899
  • Fax: 847-381-8999
Mailing address:
  • Phone: 847-381-8899
  • Fax: 847-381-8999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number125059230
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberL-240236
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: