Healthcare Provider Details

I. General information

NPI: 1407554066
Provider Name (Legal Business Name): ANDREW VICTOR MARINICH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2023
Last Update Date: 08/16/2023
Certification Date: 08/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 W BELVEDERE AVE
BALTIMORE MD
21215-5216
US

IV. Provider business mailing address

507 N 17TH STREET
MILWAUKEE WI
53233
US

V. Phone/Fax

Practice location:
  • Phone: 410-601-2663
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberC09018
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: