Provider Demographics
NPI:1083657894
Name:MCKENZIE, AMY L (MD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:L
Last Name:MCKENZIE
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 1:15501 METROPOLITAN PKWY
Mailing Address - Street 2:STE 110
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-1684
Mailing Address - Country:US
Mailing Address - Phone:586-286-9720
Mailing Address - Fax:586-286-3134
Practice Address - Street 1:15501 METROPOLITAN PKWY
Practice Address - Street 2:STE 110
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48036-1684
Practice Address - Country:US
Practice Address - Phone:586-286-9720
Practice Address - Fax:586-286-3134
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAM069839174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0501612OtherBLUE CROSS BLUE SHIELD
MIOP03910002Medicare ID - Type Unspecified
MI0501612OtherBLUE CROSS BLUE SHIELD