Provider Demographics
NPI:1063646370
Name:FOTHERGILL, AMY L (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:FOTHERGILL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4410 REGENT ST
Mailing Address - Street 2:ASSOCIATED PHYSICIANS, LLP
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-4901
Mailing Address - Country:US
Mailing Address - Phone:608-233-9746
Mailing Address - Fax:
Practice Address - Street 1:4410 REGENT ST
Practice Address - Street 2:ASSOCIATED PHYSICIANS, LLP
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-4901
Practice Address - Country:US
Practice Address - Phone:608-233-9746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-14
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI55468-20207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1063646370Medicaid
WI55468-20OtherSTATE LICENSE NUMBER