MEDICARE: ERIC C AMBERG PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103G00000X	Clinical Neuropsychologist	6301003725	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	680H145160	OTHER	MI	BLUE CROSS OF MICHIGAN

General Provider Information

NPI Number	:	1588732937
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIC C AMBERG PHD

Provider Business Mailing Address
First Line	:	PO BOX 130236
Second Line	:
City	:	ANN ARBOR
State	:	MI
Zip	:	48113-0236
Country	:	US
Telephone Number	:	734-677-0696
Fax Number	:	734-677-0699

Provider Business Practice Location Address
First Line	:	2035 HOGBACK RD
Second Line	:	SUITE 101
City	:	ANN ARBOR
State	:	MI
Zip	:	48105-9732
Country	:	US
Telephone Number	:	734-677-0696
Fax Number	:	734-677-0699

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/02/2006
Last Update Date	:	06/11/2008

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