1861452815 NPI number — MRS. AMY SUSAN PALLER MD

Table of content: MRS. AMY SUSAN PALLER MD (NPI 1861452815)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861452815 NPI number — MRS. AMY SUSAN PALLER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PALLER
Provider First Name:
AMY
Provider Middle Name:
SUSAN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COHEN
Provider Other First Name:
AMY
Provider Other Middle Name:
SUSAN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1861452815
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
BOX 107
Provider Second Line Business Mailing Address:
2300 CHILDRENS PLAZA
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60614-3394
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-227-6060
Provider Business Mailing Address Fax Number:
312-227-9402

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2515 N CLARK
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-227-6060
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  036059158 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036059158 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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