Provider Demographics
NPI:1356380950
Name:WALLACE, AMY BLAISING (DO)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:BLAISING
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3337 BRITTON RD
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:MI
Mailing Address - Zip Code:48872-9706
Mailing Address - Country:US
Mailing Address - Phone:517-625-3004
Mailing Address - Fax:517-625-5001
Practice Address - Street 1:1415 S MAIN ST
Practice Address - Street 2:
Practice Address - City:EATON RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:48827-1959
Practice Address - Country:US
Practice Address - Phone:517-663-4809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013086207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1356380950Medicaid
MI4628183TYPE11Medicaid
MIG83975Medicare UPIN
MI1356380950Medicaid