Basic Information
| Provider Information | |||||||||
| NPI: | 1568489557 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AMAYA | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | IRENE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 751461 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437926200 | ||||||||
| FaxNumber: | 8437921827 | ||||||||
| Practice Location | |||||||||
| Address1: | 171 ASHLEY AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294250100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437921414 | ||||||||
| FaxNumber: | 8437921827 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2006 | ||||||||
| LastUpdateDate: | 09/12/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 17476 | AL | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 31238 | SC | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080C0008X | 31238 | SC | Y | Allopathic & Osteopathic Physicians | Pediatrics | Child Abuse Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 000024694 | 05 | AL | MEDICAID | 510-24694 | 01 | AL | BC BS | OTHER | F61561 | 01 | VIVA | OTHER | 009999735 | 05 | AL | MEDICAID | 000028985 | 05 | AL | MEDICAID | 312389 | 05 | SC | MEDICAID |