=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134133762
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREA AMALFITANO D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2006
-----------------------------------------------------
Last Update Date | 08/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1600 W GRAND RIVER STE 2
-----------------------------------------------------
City | OKEMOS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48864
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-349-6560
-----------------------------------------------------
Fax | 517-349-5796
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 804 SERVICE RD # A201
-----------------------------------------------------
City | EAST LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48824-7015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-884-2976
-----------------------------------------------------
Fax | 517-432-3928
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207SG0201X
-----------------------------------------------------
Taxonomy Name | Clinical Genetics (M.D.) Physician
-----------------------------------------------------
License Number | 5101011076
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------