1407816143 NPI number — KATHLEEN D AMBROSE NP

Table of content: KATHLEEN D AMBROSE NP (NPI 1407816143)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407816143 NPI number — KATHLEEN D AMBROSE NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AMBROSE
Provider First Name:
KATHLEEN
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407816143
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
64580 VAN DYKE RD
Provider Second Line Business Mailing Address:
STE C
Provider Business Mailing Address City Name:
WASHINGTON TOWNSHIP
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48095-2811
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-226-6865
Provider Business Mailing Address Fax Number:
586-226-6880

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
64580 VAN DYKE RD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48095-2857
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-752-9629
Provider Business Practice Location Address Fax Number:
586-752-4099
Provider Enumeration Date:
03/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163WG0000X , with the licence number:  470413564 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 4704131564 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 50-0866503-0 . This is a "BCBS PIN NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4378376 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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