Basic Information
| Provider Information | |||||||||
| NPI: | 1144273392 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AMBROSIA | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1615 MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | BALDWIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493047984 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317455045 | ||||||||
| FaxNumber: | 2317455031 | ||||||||
| Practice Location | |||||||||
| Address1: | 1035 E WILCOX AVE | ||||||||
| Address2: | |||||||||
| City: | WHITE CLOUD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493498794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2316895943 | ||||||||
| FaxNumber: | 2316891590 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 09/06/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301406924 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2427880 | 01 | MI | CIGNA | OTHER | 1851478 | 01 | MI | UNITED HEALTH CARE | OTHER | 4112710 | 01 | MI | AETNA PROVIDER NUMBER | OTHER | 700H21076 | 01 | MI | BCBSM | OTHER | CC3713 | 01 | MI | RR MEDICARE | OTHER | 4301406924 | 01 | MI | PHYSICIAN LICENSE | OTHER |