Provider Demographics
NPI:1396816096
Name:AMBROSE, FREDERICK P (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:P
Last Name:AMBROSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 W IRONWOOD DRIVE
Mailing Address - Street 2:SUITE 306
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2668
Mailing Address - Country:US
Mailing Address - Phone:208-664-3101
Mailing Address - Fax:208-664-9713
Practice Address - Street 1:980 W IRONWOOD DRIVE
Practice Address - Street 2:SUITE 306
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2601
Practice Address - Country:US
Practice Address - Phone:208-664-3101
Practice Address - Fax:208-664-9713
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3731207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D93681Medicare UPIN
ID1112220Medicare ID - Type Unspecified