Provider Demographics
NPI:1457367070
Name:VIVIAN WOMENS CENTER, INC
Entity Type:Organization
Organization Name:VIVIAN WOMENS CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GEORGIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:AMIEWALAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-422-0560
Mailing Address - Street 1:1750 E LAKE SHORE DR
Mailing Address - Street 2:SUITE 320
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521
Mailing Address - Country:US
Mailing Address - Phone:217-422-0560
Mailing Address - Fax:217-422-0872
Practice Address - Street 1:1750 EAST LAKE SHORE DR SUITE 320
Practice Address - Street 2:ANTHONY O AMIEWALAN,M.D. SC
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521
Practice Address - Country:US
Practice Address - Phone:217-422-0560
Practice Address - Fax:217-422-0872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2009-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112019207VG0400X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036112019Medicaid
X10386Medicare UPIN
B65621Medicare ID - Type Unspecified