=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548464035
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA ROSE HENRY DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2007
-----------------------------------------------------
Last Update Date | 01/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6505 CONSTITUTION BLVD STE C
-----------------------------------------------------
City | PORTAGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49024-1605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-762-4120
-----------------------------------------------------
Fax | 269-254-8413
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6505 CONSTITUTION BLVD STE C
-----------------------------------------------------
City | PORTAGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49024-1605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-762-4120
-----------------------------------------------------
Fax | 269-254-8413
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 5101016723
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------