NPIMap

Individual provider Active NPI

Amy Blaising Wallace, D.O.

  • Family Medicine Physician
  • Eaton Rapids, MI
National Provider Identifier
1356380950
Registry record updated Dec 17, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
5101013086 Issued in MI
Practice address
1415 S Main St
Eaton Rapids, MI 48827-1959
Phone
(517) 663-4809
NPI assigned
Jun 6, 2006
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Dec 17, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 5101013086 MI Primary

Addresses

Primary practice location

1415 S Main St
Eaton Rapids, MI 48827-1959

Mailing address

3337 Britton Rd
Perry, MI 48872-9706
Phone (517) 625-3004

Other practice location 1

3337 Britton Rd
Perry, MI 48872-9706
Phone (517) 625-3004

Other identifiers 2

IdentifierTypeStateIssuer
1356380950MedicaidMI
4628183TYPE11MedicaidMI

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20040802000053 MI Practitioner - Family Practice 6507837903 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
Michigan State University College of Osteopathic Medicine, 1996
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Sparrow Eaton HospitalGroup PAC ID 0042103509, shared by 4 NPIs, 45 clinicians

Practice addresses (Care Compare)

123 Lansing St
Suite 3a
Charlotte, MI 48813-1696
Phone (517) 543-0600

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Osteopathy

Practice roles

OrganizationSpecialtyStatusNew patients
Sparrow Eaton Hospital Current Accepting new patients
Sparrow Eaton Hospital Current Accepting new patients
Amy Blaising Wallace, D.O. PLC Family Medicine CurrentSince May 24, 2004 Accepting new patients
Memorial Hospital Family Medicine Past Accepting new patients
Metropolitan Hospital Past Accepting new patients
Memorial Hospital Past Accepting new patients
Sparrow Eaton Hospital Past Accepting new patients

Locations

8175 Reliable Pkwy
Chicago, IL 60686

321 E Harris St
Charlotte, MI 48813
Phone (517) 541-5840

123 Lansing St
Ste 2
Charlotte, MI 48813
Phone (517) 541-5954

111 Lansing St
Ste 230
Charlotte, MI 48813
Phone (517) 543-5110

818 W King St
Ste 103
Owosso, MI 48867
Phone (989) 723-8333

Interoperability endpoints

  • Direct secure messaging: ablaisingwallace68998@sparrowdirecthie.org

Organizations & group practices 7

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 6

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1149552000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1545004800000",
    "number": "1356380950",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3337 BRITTON RD",
            "city": "PERRY",
            "state": "MI",
            "postal_code": "488729706",
            "telephone_number": "517-625-3004",
            "fax_number": "517-625-5001"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1415 S MAIN ST",
            "city": "EATON RAPIDS",
            "state": "MI",
            "postal_code": "488271959",
            "telephone_number": "517-663-4809"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "3337 Britton Rd",
            "address_purpose": "LOCATION",
            "city": "Perry",
            "state": "MI",
            "postal_code": "488729706",
            "country_code": "US",
            "telephone_number": "517-625-3004",
            "fax_number": "517-625-5001",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "AMY",
        "middle_name": "BLAISING",
        "credential": "D.O.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-06-06",
        "last_updated": "2018-12-17",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MI",
            "license": "5101013086",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1356380950",
            "state": "MI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "4628183TYPE11",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Eaton Rapids, MI

Sources for this page

Verify at the official NPI Registry.