Healthcare Provider Details

I. General information

NPI: 1275454746
Provider Name (Legal Business Name): ZACHARY AMBROSE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 08/08/2026
Certification Date: 08/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18101 OAKWOOD BLVD
DEARBORN MI
48124-4089
US

IV. Provider business mailing address

18101 OAKWOOD BLVD
DEARBORN MI
48124-4089
US

V. Phone/Fax

Practice location:
  • Phone: 313-593-7000
  • Fax:
Mailing address:
  • Phone: 313-593-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704358560
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704358560
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: