Healthcare Provider Details

I. General information

NPI: 1134104177
Provider Name (Legal Business Name): AMY JO MCMICHAEL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 10/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4618 COUNTRY CLUB RD
WINSTON SALEM NC
27104-3520
US

IV. Provider business mailing address

PO BOX 344
WINSTON SALEM NC
27102-0344
US

V. Phone/Fax

Practice location:
  • Phone: 336-716-2255
  • Fax: 336-716-9258
Mailing address:
  • Phone: 336-716-2255
  • Fax: 336-716-9258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number9400925
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: