Provider Demographics
NPI:1356442172
Name:LARSON, AMY S (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:S
Last Name:LARSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:S
Other - Last Name:FLEISHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:834 N SEMINARY ST
Mailing Address - Street 2:SUITE 304
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-2852
Mailing Address - Country:US
Mailing Address - Phone:309-342-2144
Mailing Address - Fax:309-342-5104
Practice Address - Street 1:834 N SEMINARY ST
Practice Address - Street 2:SUITE 304
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-2852
Practice Address - Country:US
Practice Address - Phone:309-342-2144
Practice Address - Fax:309-342-5104
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036106772208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036106772Medicaid
4815127OtherBC/BS
7860434OtherAETNA
11053882OtherCAQH
364271985-28OtherJOHN DEERE
IL530390Medicare ID - Type Unspecified
11053882OtherCAQH
ILH76423Medicare UPIN