Provider Demographics
NPI:1700194339
Name:LAUREEN L AMBROSE MD SC
Entity Type:Organization
Organization Name:LAUREEN L AMBROSE MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:LAUREEN
Authorized Official - Middle Name:
Authorized Official - Last Name:AMBROSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-460-1040
Mailing Address - Street 1:15300 WEST AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-4600
Mailing Address - Country:US
Mailing Address - Phone:708-460-1040
Mailing Address - Fax:708-460-6872
Practice Address - Street 1:15300 WEST AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-4600
Practice Address - Country:US
Practice Address - Phone:708-460-1040
Practice Address - Fax:708-460-6872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-16
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-059550207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL718990OtherMEDICARE
IL31600367OtherBLUECROSS & BLUESHIELD
IL31600367OtherBLUECROSS & BLUESHIELD