Provider Demographics
NPI:1881033694
Name:NORTHUP, AMANDA FAYE (MD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:FAYE
Last Name:NORTHUP
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:PO BOX 751461
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1461
Mailing Address - Country:US
Mailing Address - Phone:843-792-6200
Mailing Address - Fax:
Practice Address - Street 1:169 ASHLEY AVE
Practice Address - Street 2:ROOM 202 MAIN HOSPITAL, MSC333
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-8905
Practice Address - Country:US
Practice Address - Phone:843-792-1020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-14
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC35918207RC0000X
SCLL35918207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease