Provider Demographics
NPI:1104011394
Name:OVERMYER, AMANDA JO (MD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:JO
Last Name:OVERMYER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:JO
Other - Last Name:KUSEBUSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:922 LAWNDALE ST
Practice Address - Street 2:
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-1928
Practice Address - Country:US
Practice Address - Phone:231-845-7380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301090734207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0530013OtherBCBS
MI1104011394Medicaid
FO1576745OtherDEA
4301090734OtherLICENCE
FO1576745OtherCONTROLLED SUBSTANCE
N11460003Medicare PIN