Healthcare Provider Details

I. General information

NPI: 1609841956
Provider Name (Legal Business Name): ANDREW JOHN NINICHUCK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 11/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

527 BENHAM ST
BONNE TERRE MO
63628-1205
US

IV. Provider business mailing address

527 BENHAM ST
BONNE TERRE MO
63628-1205
US

V. Phone/Fax

Practice location:
  • Phone: 573-358-9119
  • Fax: 573-358-9489
Mailing address:
  • Phone: 573-358-9119
  • Fax: 573-358-9489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number102387
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: