Provider Demographics
NPI:1801863188
Name:GOLDFADEN, AMY (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:GOLDFADEN
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 1:5777 W MAPLE RD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-2267
Mailing Address - Country:US
Mailing Address - Phone:248-406-1000
Mailing Address - Fax:248-406-1001
Practice Address - Street 1:5777 W MAPLE RD
Practice Address - Street 2:SUITE 140
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-2267
Practice Address - Country:US
Practice Address - Phone:248-406-1000
Practice Address - Fax:248-406-1001
Is Sole Proprietor?:No
Enumeration Date:2006-03-04
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301048903207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4619237Medicaid
A73948Medicare UPIN
N91620016Medicare ID - Type Unspecified