Provider Demographics
NPI:1457367070
Name:ANTHONY O AMIEWALAN MD, SC
Entity type:Organization
Organization Name:ANTHONY O AMIEWALAN MD, SC
Other - Org Name:<UNAVAIL>
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 1:2965 N MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-4397
Mailing Address - Country:US
Mailing Address - Phone:217-422-0560
Mailing Address - Fax:217-422-0872
Practice Address - Street 1:2965 N MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4397
Practice Address - Country:US
Practice Address - Phone:217-422-0560
Practice Address - Fax:217-422-0872
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VIVIAN WOMENS CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-01
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112019207VG0400X, 207VX0000X
207VG0400X, 261Q00000X, 261QP2300X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036112019Medicaid
X10386Medicare UPIN
B65621Medicare ID - Type Unspecified