Provider Demographics
NPI:1093837718
Name:SHEPARD, AMY RUTH (DO)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:RUTH
Last Name:SHEPARD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:MISS
Other - First Name:AMY
Other - Middle Name:RUTH
Other - Last Name:GALLAGHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:102 N ADELAIDE ST
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-2670
Mailing Address - Country:US
Mailing Address - Phone:810-629-2245
Mailing Address - Fax:810-629-6535
Practice Address - Street 1:102 N ADELAIDE ST
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-2670
Practice Address - Country:US
Practice Address - Phone:810-629-2245
Practice Address - Fax:810-629-6535
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101016885207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0B56256023Medicare PIN