Active NPI
Amanda Micklo, DO
- Internal Medicine Physician
- Evanston, IL
National Provider Identifier
1619771508
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Internal Medicine Physician
- License
- 125.085423
- Practice address
- 2650 Ridge Ave Ste 1304
Evanston, IL 60201-1700 - Phone
- (847) 570-2700
- Fax
- (847) 570-2822
- NPI assigned
- Apr 1, 2025
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Internal Medicine Physician | 207R00000X | 125.085423 | IL | Primary |
Addresses
Primary practice location
2650 Ridge Ave Ste 1304
Evanston, IL 60201-1700
Mailing address
180 Harvester Dr Ste 110
Burr Ridge, IL 60527-6686
Phone (773) 702-1150
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in IL
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20250708000575 | IL | Order and Referring Only - Internal Medicine | 0244744803 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Osteopathy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 125.085423 | IL | MD | Internal Medicine Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1743465600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1752537600000",
"number": "1619771508",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "180 HARVESTER DR STE 110",
"city": "BURR RIDGE",
"state": "IL",
"postal_code": "605276686",
"telephone_number": "773-702-1150"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2650 RIDGE AVE STE 1304",
"city": "EVANSTON",
"state": "IL",
"postal_code": "602011700",
"telephone_number": "847-570-2700",
"fax_number": "847-570-2822"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MICKLO",
"first_name": "AMANDA",
"credential": "DO",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2025-04-01",
"last_updated": "2025-07-15",
"certification_date": "2025-07-15",
"status": "A"
},
"taxonomies": [
{
"code": "207R00000X",
"taxonomy_group": "",
"desc": "Internal Medicine",
"state": "IL",
"license": "125.085423",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Evanston, IL
- Amanda L. Michalek, APN-CNP
- Zachary David Michalicek, D.O.
- Michelle Ferris, LCSW, PLLC
- Margaret Gross Michelson, M.D.
- Lisa Marie Michener, PHARM.D., M.S.
- Kathleen Patricia Mickow, FNP-BC
- Midwest Allied Pathologists LLC
- Midwest Center for Women'S Healthcare
- Midwest Center for Women'S Healthcare
- Mie Tamura
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 15, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.