Healthcare Provider Details

I. General information

NPI: 1356380950
Provider Name (Legal Business Name): AMY BLAISING WALLACE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 12/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 S MAIN ST
EATON RAPIDS MI
48827-1959
US

IV. Provider business mailing address

3337 BRITTON RD
PERRY MI
48872-9706
US

V. Phone/Fax

Practice location:
  • Phone: 517-663-4809
  • Fax:
Mailing address:
  • Phone: 517-625-3004
  • Fax: 517-625-5001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101013086
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: