Healthcare Provider Details

I. General information

NPI: 1396061933
Provider Name (Legal Business Name): ANDREW D. BICKHAM IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2010
Last Update Date: 04/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 TROUT AVENUE
GROTON CT
06340
US

IV. Provider business mailing address

9 CORMORANT RD
GROTON CT
06340-3110
US

V. Phone/Fax

Practice location:
  • Phone: 860-694-2876
  • Fax:
Mailing address:
  • Phone: 703-258-9239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License NumberT69-52-2586
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: