Provider Demographics
NPI:1467444620
Name:AMENTA, CHARLES ANTHONY III (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ANTHONY
Last Name:AMENTA
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:18161 MORRIS AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-2108
Mailing Address - Country:US
Mailing Address - Phone:708-799-5520
Mailing Address - Fax:708-799-5358
Practice Address - Street 1:18161 MORRIS AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-2108
Practice Address - Country:US
Practice Address - Phone:708-799-5520
Practice Address - Fax:708-799-5358
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036075600174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036075600Medicaid
GA040010012OtherRAILROAD MEDICARE
TX05055067OtherAETNA
IL01606798OtherBLUE CROSS BLUE SHIELD