Mark Ambrose, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

085000830 Issued in IL

Practice address

3330 W 177TH St
Suite 3E
Hazel Crest, IL 60429-2184

Phone

(708) 206-0010

Fax

(708) 206-0020

NPI assigned

May 10, 2007

Sex

Male

Sole proprietor

No

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on May 13, 2016.

{
    "created_epoch": "1178755200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1463097600000",
    "number": "1043424740",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "16450 104TH AVE",
            "address_2": "STE 101",
            "city": "ORLAND PARK",
            "state": "IL",
            "postal_code": "604675416",
            "telephone_number": "708-206-0010",
            "fax_number": "708-206-0020"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3330 W 177TH ST",
            "address_2": "SUITE 3E",
            "city": "HAZEL CREST",
            "state": "IL",
            "postal_code": "604292184",
            "telephone_number": "708-206-0010",
            "fax_number": "708-206-0020"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "AMBROSE",
        "first_name": "MARK",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-05-10",
        "last_updated": "2016-05-13",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "IL",
            "license": "085000830",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PROVIDER NO.",
            "identifier": "K18310SC",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Natalie Allen, LCPC
• Abdulah Alrifai, M.D.
• Shadwan F Alsafwah, MD
• Ayman Alzubi, MD
• Amarjit S Bhasin MD LTD
• American Therapy Providers LLC.
• Veronica Jane Ammar
• Amanda Anderson, DPT
• Rebecca Lynn Anderson, PTA, ATC
• Apex Behavioral Consultants

• All providers in Hazel Crest, IL
• Physician Assistant in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 13, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.