Provider Demographics
NPI:1710902077
Name:AMBROSE, LAUREEN L (MD SC)
Entity Type:Individual
Prefix:
First Name:LAUREEN
Middle Name:L
Last Name:AMBROSE
Suffix:
Gender:F
Credentials:MD SC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-059550174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL31600367OtherBLUE CROSS BLUE SHIELD
IL363320772OtherTAX ID NUMBER
ILD151315Medicare UPIN
IL718990Medicare ID - Type Unspecified