Provider Demographics
NPI:1194733584
Name:AMPALLOOR, GEORGE THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:THOMAS
Last Name:AMPALLOOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1044 N MOZART ST
Mailing Address - Street 2:SUITE 402
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2789
Mailing Address - Country:US
Mailing Address - Phone:773-292-4501
Mailing Address - Fax:773-292-2613
Practice Address - Street 1:1044 N MOZART ST
Practice Address - Street 2:SUITE 402
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-2789
Practice Address - Country:US
Practice Address - Phone:773-292-4501
Practice Address - Fax:773-292-2613
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036-105483208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036105483Medicaid