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NPI Code Detail

MEDICARE: DR. TRAVIS MARK AMENGUAL MD

MEDICARE: DR. TRAVIS MARK AMENGUAL MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12084P0800XPsychiatry Physician036.153670IL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1386147163
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. TRAVIS MARK AMENGUAL MD
Provider Business Mailing Address
First Line : 5537 N BROADWAY ST
Second Line :
City : CHICAGO
State : IL
Zip : 60640-1405
Country : US
Telephone Number : 177-398-9940
Fax Number : 773-648-7834
Provider Business Practice Location Address
First Line : 3948 N SHERIDAN RD STE 100
Second Line :
City : CHICAGO
State : IL
Zip : 60613-2935
Country : US
Telephone Number : 773-388-1600
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/17/2018
Last Update Date : 05/26/2026

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