Healthcare Provider Details

I. General information

NPI: 1629230156
Provider Name (Legal Business Name): AMANDA MARIE MCCLURE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2008
Last Update Date: 11/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5325 ELLIOTT DR SUITE 104
YPSILANTI MI
48197-8633
US

IV. Provider business mailing address

24 FRANK LLOYD WRIGHT DR PO BOX 0446 LOBBY J
ANN ARBOR MI
48105-9484
US

V. Phone/Fax

Practice location:
  • Phone: 734-712-8150
  • Fax: 734-712-8151
Mailing address:
  • Phone: 734-747-6766
  • Fax: 734-222-3100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301092562
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberME115518
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberMD166048
License Number StateOR
# 4
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number4301092562
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: