Provider Demographics
NPI:1508136102
Name:BUCHANAN, AMANDA (MD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BUCHANAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 N CUYLER AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-2378
Mailing Address - Country:US
Mailing Address - Phone:630-740-8243
Mailing Address - Fax:
Practice Address - Street 1:1225 W LAKE ST
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-4039
Practice Address - Country:US
Practice Address - Phone:708-938-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-12
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125060715207R00000X
IL036136914207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214881Medicare Oscar/Certification