MEDICARE: RICHARD F AMBROSE JR DPM PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist	5901001007	MI

General Provider Information

NPI Number	:	1104106020
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RICHARD F AMBROSE JR DPM PC

Provider Business Mailing Address
First Line	:	16170 FRANKLIN RD
Second Line	:
City	:	NORTHVILLE
State	:	MI
Zip	:	48168-9515
Country	:	US
Telephone Number	:	734-425-4000
Fax Number	:

Provider Business Practice Location Address
First Line	:	415 MILL RD
Second Line	:
City	:	ADRIAN
State	:	MI
Zip	:	49221-1764
Country	:	US
Telephone Number	:	517-263-0427
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RICHARD AMBROSE JR.
Credential	:	D.P.M.
Telephone Number	:	734-425-4000

Provider Enumeration Date	:	08/23/2011
Last Update Date	:	08/23/2011

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