Basic Information
| Provider Information | |||||||||
| NPI: | 1285256966 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GHUMAN | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | NAVREET | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | JAVON BEA HOSPITAL - ROCKTON AVENUE | ||||||||
| Address2: | 2400 NORTH ROCKTON AVENUE | ||||||||
| City: | RICKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159715000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | MERCYHEALTH JAVON BEA HOSPITAL | ||||||||
| Address2: | 8201 EAST RIVERSIDE BOULEVARD | ||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159715000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2020 | ||||||||
| LastUpdateDate: | 03/16/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 02/10/2022 | ||||||||
| NPIReactivationDate: | 03/16/2022 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.