Provider Demographics
NPI:1053543215
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:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:O
Authorized Official - Last Name:AMIEWALAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-422-0560
Mailing Address - Street 1:2665 NORTH MAIN STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-3803
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?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-20
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112019173000000X
261Q00000X, 261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service