Provider Demographics
NPI:1144273392
Name:AMBROSIA, ANGELA E (MD)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:E
Last Name:AMBROSIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:MI
Mailing Address - Zip Code:49304-7984
Mailing Address - Country:US
Mailing Address - Phone:231-745-5045
Mailing Address - Fax:231-745-5031
Practice Address - Street 1:1035 E WILCOX AVE
Practice Address - Street 2:
Practice Address - City:WHITE CLOUD
Practice Address - State:MI
Practice Address - Zip Code:49349-8794
Practice Address - Country:US
Practice Address - Phone:231-689-5943
Practice Address - Fax:231-689-1590
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301406924207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2427880OtherCIGNA
MI1851478OtherUNITED HEALTH CARE
MI4112710OtherAETNA PROVIDER NUMBER
MI700H21076OtherBCBSM
MICC3713OtherRR MEDICARE
MI4301406924OtherPHYSICIAN LICENSE
MI2427880OtherCIGNA
MIE16188Medicare UPIN