Healthcare Provider Details

I. General information

NPI: 1902057607
Provider Name (Legal Business Name): MARINA ANDROSSOVA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2008
Last Update Date: 01/12/2023
Certification Date: 01/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11380 SW VILLAGE PKWY
PORT ST LUCIE FL
34987-2388
US

IV. Provider business mailing address

11380 SW VILLAGE PKWY
PORT ST LUCIE FL
34987-2388
US

V. Phone/Fax

Practice location:
  • Phone: 772-301-6565
  • Fax: 843-777-5135
Mailing address:
  • Phone: 772-301-6565
  • Fax: 843-777-5135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License NumberME160289
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: