Healthcare Provider Details

I. General information

NPI: 1841686821
Provider Name (Legal Business Name): ANDREW MAY OTR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2015
Last Update Date: 04/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N WEST AVE
JACKSON MI
49202-2179
US

IV. Provider business mailing address

PO BOX 4230
JACKSON MI
49204-4230
US

V. Phone/Fax

Practice location:
  • Phone: 517-262-6186
  • Fax:
Mailing address:
  • Phone: 517-812-9639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number5201006259
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: