Provider Demographics
NPI:1598971327
Name:DEROSA, AMY PHILOMENA (DO)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:PHILOMENA
Last Name:DEROSA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:33200 W 14 MILE RD STE 180
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3587
Mailing Address - Country:US
Mailing Address - Phone:248-688-7597
Mailing Address - Fax:248-498-6060
Practice Address - Street 1:33200 W 14 MILE RD STE 180
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3587
Practice Address - Country:US
Practice Address - Phone:248-688-7597
Practice Address - Fax:248-498-6060
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101017043208200000X, 208600000X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1598971327Medicaid