Provider Demographics
NPI:1932662699
Name:MARSHALL, AMANDA-LYNN (MD)
Entity Type:Individual
Prefix:
First Name:AMANDA-LYNN
Middle Name:
Last Name:MARSHALL
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 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1848
Mailing Address - Fax:947-522-0307
Practice Address - Street 1:36555 26 MILE RD STE 1100
Practice Address - Street 2:
Practice Address - City:LENOX
Practice Address - State:MI
Practice Address - Zip Code:48048-3186
Practice Address - Country:US
Practice Address - Phone:947-523-4040
Practice Address - Fax:947-523-4011
Is Sole Proprietor?:No
Enumeration Date:2019-04-10
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4301506471207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program