Provider Demographics
NPI:1598744690
Name:AMEDURE, AMY JEANNE BRUECKNER (DO)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JEANNE BRUECKNER
Last Name:AMEDURE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 WOODLAND LN
Mailing Address - Street 2:
Mailing Address - City:PALENVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12463-2525
Mailing Address - Country:US
Mailing Address - Phone:518-542-4643
Mailing Address - Fax:
Practice Address - Street 1:14 BRISTOL LN
Practice Address - Street 2:
Practice Address - City:ELLICOTTVILLE
Practice Address - State:NY
Practice Address - Zip Code:14731
Practice Address - Country:US
Practice Address - Phone:716-699-9032
Practice Address - Fax:716-699-9035
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY233710207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02701077Medicaid
NY2709P1Medicare PIN
NYI37364Medicare UPIN