Provider Demographics
NPI:1104106020
Name:RICHARD F AMBROSE JR DPM PC
Entity type:Organization
Organization Name:RICHARD F AMBROSE JR DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:AMBROSE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPM
Authorized Official - Phone:734-425-4000
Mailing Address - Street 1:16170 FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48168-9515
Mailing Address - Country:US
Mailing Address - Phone:734-425-4000
Mailing Address - Fax:
Practice Address - Street 1:415 MILL RD
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1764
Practice Address - Country:US
Practice Address - Phone:517-263-0427
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-23
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001007213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
T-34310Medicare UPIN