Provider Demographics
NPI:1578632246
Name:BRADDOCK, AMY L (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:BRADDOCK
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 1:44555 WOODWARD AVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341
Mailing Address - Country:US
Mailing Address - Phone:248-338-7171
Mailing Address - Fax:248-858-3830
Practice Address - Street 1:44555 WOODWARD AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341
Practice Address - Country:US
Practice Address - Phone:248-338-7171
Practice Address - Fax:248-858-3830
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301074104208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
0206348782OtherBCBSM
MI4736387Medicaid
AB074104OtherSTATE LICENSE
P17040001Medicare ID - Type Unspecified
I31063Medicare UPIN