Basic Information
| Provider Information | |||||||||
| NPI: | 1134619463 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | AMY | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 660 MILFORD FARMS CT | ||||||||
| Address2: | |||||||||
| City: | MILFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483813351 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 28050 GRAND RIVER AVE | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483365919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484718822 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2018 | ||||||||
| LastUpdateDate: | 06/30/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 1134619463 | MI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 5101026825 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.