Provider Demographics
NPI:1861452815
Name:PALLER, AMY SUSAN (MD)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:SUSAN
Last Name:PALLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:SUSAN
Other - Last Name:COHEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:BOX 107
Mailing Address - Street 2:2300 CHILDRENS PLAZA
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-3394
Mailing Address - Country:US
Mailing Address - Phone:312-227-6060
Mailing Address - Fax:312-227-9402
Practice Address - Street 1:2515 N CLARK
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614
Practice Address - Country:US
Practice Address - Phone:312-227-6060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036059158208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036059158Medicaid
ILP08835Medicare ID - Type Unspecified
IL036059158Medicaid