Provider Demographics
NPI:1336119064
Name:AMADOR, NELLY Y (MD, PMD)
Entity Type:Individual
Prefix:
First Name:NELLY
Middle Name:Y
Last Name:AMADOR
Suffix:
Gender:F
Credentials:MD, PMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 N ROCKTON AVE
Mailing Address - Street 2:EMERGENCY MEDICINE DEPT
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61103-3655
Mailing Address - Country:US
Mailing Address - Phone:815-971-3333
Mailing Address - Fax:815-968-0360
Practice Address - Street 1:205 PARKER ST
Practice Address - Street 2:
Practice Address - City:BOSCOBEL
Practice Address - State:WI
Practice Address - Zip Code:53805-1642
Practice Address - Country:US
Practice Address - Phone:608-375-4112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036136816207P00000X
MN48093207T00000X
WI66004207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN140000420Medicare PIN
I47425Medicare UPIN
MN140000315Medicare ID - Type Unspecified