Provider Demographics
NPI:1134104177
Name:MCMICHAEL, AMY JO (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JO
Last Name:MCMICHAEL
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:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27102-0344
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:336-716-9258
Practice Address - Street 1:4618 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-3520
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:336-716-9258
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC9400925207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6840OtherPARTNERS
NC64000OtherMEDCOST
NC57811OtherBCBS
VA5900514Medicaid
SCQ00930Medicaid
WV2005320000Medicaid
4633020OtherAETNA
NC8957811Medicaid
NC6840OtherPARTNERS
NC64000OtherMEDCOST