Healthcare Provider Details

I. General information

NPI: 1730996844
Provider Name (Legal Business Name): AMRITPAL LALL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2024
Last Update Date: 02/03/2025
Certification Date: 02/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 WINDING WOODS DR STE 214
O FALLON MO
63366-4773
US

IV. Provider business mailing address

PO BOX 776084
CHICAGO IL
60677-6084
US

V. Phone/Fax

Practice location:
  • Phone: 636-978-8600
  • Fax:
Mailing address:
  • Phone: 636-614-3280
  • Fax: 636-272-3680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2024047257
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: