1629230156 NPI number — DR. AMANDA MARIE MCCLURE MD

Table of content: DR. AMANDA MARIE MCCLURE MD (NPI 1629230156)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629230156 NPI number — DR. AMANDA MARIE MCCLURE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCLURE
Provider First Name:
AMANDA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1629230156
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24 FRANK LLOYD WRIGHT DR
Provider Second Line Business Mailing Address:
PO BOX 0446 LOBBY J
Provider Business Mailing Address City Name:
ANN ARBOR
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48105-9484
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-747-6766
Provider Business Mailing Address Fax Number:
734-222-3100

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5325 ELLIOTT DR
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
YPSILANTI
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48197-8633
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-712-8150
Provider Business Practice Location Address Fax Number:
734-712-8151
Provider Enumeration Date:
06/26/2008

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: 208600000X , with the licence number:  4301092562 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 390200000X , with the licence number: ME115518 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208C00000X , with the licence number: MD166048 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208C00000X , with the licence number: 4301092562 , 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)