Provider Demographics
NPI:1558379024
Name:AMBROSE, STEVEN E (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:E
Last Name:AMBROSE
Suffix:
Gender:M
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 1:9730 S WESTERN AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-2814
Mailing Address - Country:US
Mailing Address - Phone:708-425-1907
Mailing Address - Fax:708-422-4253
Practice Address - Street 1:9730 S WESTERN AVE
Practice Address - Street 2:STE 100
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2814
Practice Address - Country:US
Practice Address - Phone:708-425-1907
Practice Address - Fax:708-422-4253
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036079951207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036079951Medicaid
IL036079951Medicaid
ILE64519Medicare UPIN