Provider Demographics
NPI:1811987647
Name:AMESBURY, STEPHEN R (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:R
Last Name:AMESBURY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:7607 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60130-3513
Mailing Address - Country:US
Mailing Address - Phone:708-450-4557
Mailing Address - Fax:708-338-0200
Practice Address - Street 1:675 W NORTH AVE
Practice Address - Street 2:SUITE 214
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1634
Practice Address - Country:US
Practice Address - Phone:708-450-4557
Practice Address - Fax:708-338-0200
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036080212207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036080212Medicaid
IL31601838OtherBCBS
F65792Medicare UPIN
IL202963Medicare ID - Type Unspecified
IL31601838OtherBCBS