Healthcare Provider Details

I. General information

NPI: 1124346325
Provider Name (Legal Business Name): ANDREA MIKOL HEUSER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANDREA LYNN MIKOL

II. Dates (important events)

Enumeration Date: 05/12/2010
Last Update Date: 01/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4750 WATERS AVE STE 206
SAVANNAH GA
31404-6278
US

IV. Provider business mailing address

4750 WATERS AVE STE 206
SAVANNAH GA
31404-6278
US

V. Phone/Fax

Practice location:
  • Phone: 912-350-5915
  • Fax: 912-350-5930
Mailing address:
  • Phone: 912-350-5915
  • Fax: 912-350-5930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number36347
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number80856
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: