Basic Information
| Provider Information | |||||||||
| NPI: | 1801863188 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOLDFADEN | ||||||||
| FirstName: | AMY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5777 W MAPLE RD | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | WEST BLOOMFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483222267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484061000 | ||||||||
| FaxNumber: | 2484061001 | ||||||||
| Practice Location | |||||||||
| Address1: | 5777 W MAPLE RD | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | WEST BLOOMFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483222267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484061000 | ||||||||
| FaxNumber: | 2484061001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2006 | ||||||||
| LastUpdateDate: | 08/05/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301048903 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4619237 | 05 | MI | MEDICAID |