Healthcare Provider Details

I. General information

NPI: 1144478173
Provider Name (Legal Business Name): ADAM T ANGELILLI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2008
Last Update Date: 06/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 W FAIRWAY DR 2ND FLOOR (PEDIATRICS)
FREEPORT IL
61032-6600
US

IV. Provider business mailing address

1010 W FAIRWAY DR 2ND FLOOR (PEDIATRICS)
FREEPORT IL
61032-6600
US

V. Phone/Fax

Practice location:
  • Phone: 815-599-7755
  • Fax: 815-599-7627
Mailing address:
  • Phone: 815-599-7755
  • Fax: 815-599-7627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036.122065
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: