Healthcare Provider Details

I. General information

NPI: 1457367070
Provider Name (Legal Business Name): ANTHONY O AMIEWALAN MD, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 03/27/2025
Certification Date: 03/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2965 N MAIN ST STE A
DECATUR IL
62526-4397
US

IV. Provider business mailing address

2965 N MAIN ST STE A
DECATUR IL
62526-4397
US

V. Phone/Fax

Practice location:
  • Phone: 217-422-0560
  • Fax: 217-422-0872
Mailing address:
  • Phone: 217-422-0560
  • Fax: 217-422-0872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number036112019
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number036112019
License Number StateIL

VIII. Authorized Official

Name: MRS. GEORGIA M AMIEWALAN
Title or Position: BUSINESS MANAGER
Credential:
Phone: 217-422-0560