Basic Information
| Provider Information | |||||||||
| NPI: | 1598744690 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AMEDURE | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | JEANNE BRUECKNER | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 57 WOODLAND LN | ||||||||
| Address2: | |||||||||
| City: | PALENVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 124632525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185424643 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14 BRISTOL LN | ||||||||
| Address2: | |||||||||
| City: | ELLICOTTVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166999032 | ||||||||
| FaxNumber: | 7166999035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2006 | ||||||||
| LastUpdateDate: | 01/22/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 233710 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02701077 | 05 | NY | MEDICAID |