Provider Demographics
NPI:1679524805
Name:AMBROSE, THOMAS A II (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:A
Last Name:AMBROSE
Suffix:II
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 1:900 W TEMPLE AVE STE 2500
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-2121
Mailing Address - Country:US
Mailing Address - Phone:217-540-2350
Mailing Address - Fax:217-347-2323
Practice Address - Street 1:900 W TEMPLE AVE STE 2500
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-2121
Practice Address - Country:US
Practice Address - Phone:217-540-2350
Practice Address - Fax:217-347-2323
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037487A207X00000X
IA41335207X00000X
SD10090207X00000X
IL036172356207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100357760Medicaid
IN000000247026OtherANTHEM PIN
IN000000247026OtherANTHEM PIN
IN100357760Medicaid