Provider Demographics
NPI:1255429320
Name:HALLBERG, AMANDA (MD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:HALLBERG
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:DAKROUB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2800 S STATE ST
Mailing Address - Street 2:SUITE 215
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-7103
Mailing Address - Country:US
Mailing Address - Phone:734-547-3990
Mailing Address - Fax:734-547-3980
Practice Address - Street 1:2800 S STATE ST
Practice Address - Street 2:SUITE 215
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-7103
Practice Address - Country:US
Practice Address - Phone:734-547-3990
Practice Address - Fax:734-547-3980
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301081734207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4778340Medicaid
MII43498Medicare UPIN
MI0H17630110Medicare ID - Type Unspecified