Provider Demographics
NPI: | 1376594655 |
---|---|
Name: | AMOROSO, PANTALEO J (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | PANTALEO |
Middle Name: | J |
Last Name: | AMOROSO |
Suffix: | |
Gender: | M |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 675 W NORTH AVE |
Mailing Address - Street 2: | SUITE 609 |
Mailing Address - City: | MELROSE PARK |
Mailing Address - State: | IL |
Mailing Address - Zip Code: | 60160-1634 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 708-450-5770 |
Mailing Address - Fax: | 708-681-7675 |
Practice Address - Street 1: | 675 W NORTH AVE |
Practice Address - Street 2: | SUITE 609 |
Practice Address - City: | MELROSE PARK |
Practice Address - State: | IL |
Practice Address - Zip Code: | 60160-1634 |
Practice Address - Country: | US |
Practice Address - Phone: | 708-450-5770 |
Practice Address - Fax: | 708-681-7675 |
Is Sole Proprietor?: | Not Answered |
Enumeration Date: | 2006-05-12 |
Last Update Date: | 2022-07-21 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IL | 3647630 | 174400000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 174400000X | Other Service Providers | Specialist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IL | 21609229 | Other | BCBS IL PROVIDER NO. |
IL | 3647630 | Other | LICENSE NUMBER |
IL | 701258 | Other | UNITED HEALTHCARE |
IL | 701258 | Other | UNITED HEALTHCARE |
IL | 3647630 | Other | LICENSE NUMBER |