Provider Demographics
NPI:1154325082
Name:AVELLONE, AMANDA E (MD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:E
Last Name:AVELLONE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1390 HIGHWAY 61 STE 2300
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-4121
Mailing Address - Country:US
Mailing Address - Phone:636-937-3121
Mailing Address - Fax:636-937-4423
Practice Address - Street 1:1390 HIGHWAY 61
Practice Address - Street 2:STE 2300
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-4121
Practice Address - Country:US
Practice Address - Phone:636-937-3121
Practice Address - Fax:636-937-4423
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2004030200207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207306903Medicaid
MOP00229439OtherMEDICARE RAILROAD
MO92895463Medicare PIN