Healthcare Provider Details

I. General information

NPI: 1285609719
Provider Name (Legal Business Name): ANDREW IVAN SUMICH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2006
Last Update Date: 11/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 BALDWIN AVE
CHARLOTTE NC
28204-3109
US

IV. Provider business mailing address

225 BALDWIN AVE
CHARLOTTE NC
28204-3109
US

V. Phone/Fax

Practice location:
  • Phone: 704-376-1605
  • Fax: 704-335-8448
Mailing address:
  • Phone: 704-376-1605
  • Fax: 704-335-8448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number2005-00441
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: