Provider Demographics
NPI:1538398680
Name:AMBROSE, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:AMBROSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5036 N ILLINOIS ST STE 1
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62208-3418
Mailing Address - Country:US
Mailing Address - Phone:618-671-6800
Mailing Address - Fax:
Practice Address - Street 1:605 N 12TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864
Practice Address - Country:US
Practice Address - Phone:618-241-2212
Practice Address - Fax:618-241-2508
Is Sole Proprietor?:No
Enumeration Date:2009-07-10
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038010043111N00000X
IL036128279208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No111N00000XChiropractic ProvidersChiropractor
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist