Healthcare Provider Details

I. General information

NPI: 1134106271
Provider Name (Legal Business Name): ANDREW CARL JORGENSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 HARRY KEMP WAY
PROVINCETOWN MA
02657-1618
US

IV. Provider business mailing address

PO BOX 598
HARWICH PORT MA
02646-0598
US

V. Phone/Fax

Practice location:
  • Phone: 508-487-9395
  • Fax: 508-487-3285
Mailing address:
  • Phone: 508-905-2800
  • Fax: 508-240-1244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number234187
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number234187
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: