Provider Demographics
NPI:1366882797
Name:AMBERGER, MELISSA A (DO)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:AMBERGER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:A
Other - Last Name:JOHNS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:BELOIT HEALTH SYSTEM INC
Mailing Address - Street 2:1905 E. HUEBBE PARKWAY
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-1842
Mailing Address - Country:US
Mailing Address - Phone:608-364-2200
Mailing Address - Fax:608-364-5452
Practice Address - Street 1:BELOIT HEALTH SYSTEM INC.
Practice Address - Street 2:1905 E. HUEBBE PARKWAY
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-1842
Practice Address - Country:US
Practice Address - Phone:608-364-2200
Practice Address - Fax:608-363-7376
Is Sole Proprietor?:No
Enumeration Date:2013-06-30
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI69054-21208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100076075Medicaid