Healthcare Provider Details

I. General information

NPI: 1629123716
Provider Name (Legal Business Name): AMY R DYSART MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 INGALLS DR
HARVEY IL
60426-3558
US

IV. Provider business mailing address

150 HARVESTER DR STE 300
BURR RIDGE IL
60527-5965
US

V. Phone/Fax

Practice location:
  • Phone: 855-826-3878
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number43777
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036-165653
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: