Basic Information
Provider Information | |||||||||
NPI: | 1740417286 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LAREAU | ||||||||
FirstName: | AMANDA | ||||||||
MiddleName: | S | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SILVERIO | ||||||||
OtherFirstName: | AMANDA | ||||||||
OtherMiddleName: | M | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 525 E CONGRESS PKWY | ||||||||
Address2: | DERICK DERMATOLOGY SUITE 200 | ||||||||
City: | CRYSTAL LAKE | ||||||||
State: | IL | ||||||||
PostalCode: | 600146245 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8473818899 | ||||||||
FaxNumber: | 8473818999 | ||||||||
Practice Location | |||||||||
Address1: | 525 E CONGRESS PKWY | ||||||||
Address2: | DERICK DERMATOLOGY SUITE 200 | ||||||||
City: | CRYSTAL LAKE | ||||||||
State: | IL | ||||||||
PostalCode: | 600146245 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8473818899 | ||||||||
FaxNumber: | 8473818999 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/11/2009 | ||||||||
LastUpdateDate: | 12/16/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/16/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | L-240236 | MA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207N00000X | 125059230 | IL | Y |   | Allopathic & Osteopathic Physicians | Dermatology |   |
No ID Information.