Healthcare Provider Details

I. General information

NPI: 1154998078
Provider Name (Legal Business Name): ANDREW ANDONIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2021
Last Update Date: 06/09/2021
Certification Date: 05/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11550 WARRIOR TRAIL
GRASS LAKE MI
49240
US

IV. Provider business mailing address

114 OAK ST
BROOKLYN MI
49230-8607
US

V. Phone/Fax

Practice location:
  • Phone: 517-867-5581
  • Fax:
Mailing address:
  • Phone: 517-937-1924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number2601001733
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: