Provider Demographics
NPI:1790193084
Name:AMANDA HALLBERG MD PLLC
Entity type:Organization
Organization Name:AMANDA HALLBERG MD PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER/SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:JOY
Authorized Official - Last Name:HALLBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-547-3990
Mailing Address - Street 1:2880 S. STATE STREET
Mailing Address - Street 2:SUITE 215
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104
Mailing Address - Country:US
Mailing Address - Phone:734-547-3990
Mailing Address - Fax:734-547-3980
Practice Address - Street 1:2880 S. STATE STREET
Practice Address - Street 2:SUITE 215
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104
Practice Address - Country:US
Practice Address - Phone:734-547-3990
Practice Address - Fax:734-547-3980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-30
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301081734261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4778340Medicaid