MEDICARE: KELLY AMBROSIUS CST,CFA,RSA

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
1	363AS0400X	Surgical Physician Assistant	238.00009	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	61-1409473	OTHER	IL	FEIN

General Provider Information

NPI Number	:	1932322815
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY AMBROSIUS CST,CFA,RSA

Provider Business Mailing Address
First Line	:	PO BOX 362
Second Line	:
City	:	WADSWORTH
State	:	IL
Zip	:	60083-0362
Country	:	US
Telephone Number	:
Fax Number	:	800-560-8374

Provider Business Practice Location Address
First Line	:	39067 N CAROLINE AVE
Second Line	:	#362
City	:	WADSWORTH
State	:	IL
Zip	:	60083-7728
Country	:	US
Telephone Number	:	800-560-8374
Fax Number	:	800-560-8374

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2007
Last Update Date	:	04/01/2015

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