Healthcare Provider Details

I. General information

NPI: 1043509607
Provider Name (Legal Business Name): SEEMA R MAMTORA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2011
Last Update Date: 02/06/2024
Certification Date: 02/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 COMMERCE DR STE 700
OAK BROOK IL
60523-8865
US

IV. Provider business mailing address

1001 COMMERCE DR STE 700
OAK BROOK IL
60523-8865
US

V. Phone/Fax

Practice location:
  • Phone: 312-732-4490
  • Fax: 312-732-4491
Mailing address:
  • Phone: 312-732-4490
  • Fax: 312-732-4491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085004008
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085004008
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: