MEDICARE: AMIE JILL IRVING

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	174400000X	Specialist	041.370335	IL

General Provider Information

NPI Number	:	1932359916
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMIE JILL IRVING

Provider Business Mailing Address
First Line	:	479 BESSLER LAKE DR
Second Line	:
City	:	GROVELAND
State	:	IL
Zip	:	61535-9710
Country	:	US
Telephone Number	:	309-387-2023
Fax Number	:

Provider Business Practice Location Address
First Line	:	479 BESSLER LAKE DR
Second Line	:
City	:	GROVELAND
State	:	IL
Zip	:	61535-9710
Country	:	US
Telephone Number	:	309-387-2023
Fax Number	:

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

Provider Enumeration Date	:	09/25/2008
Last Update Date	:	09/25/2008

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