=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063779866
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANDREW J. FERCOWICZ, M.D.,P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2012
-----------------------------------------------------
Last Update Date | 04/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 202 S JOHN REDDITT DR
-----------------------------------------------------
City | LUFKIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75904-3112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-639-1005
-----------------------------------------------------
Fax | 936-639-1006
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 150137
-----------------------------------------------------
City | LUFKIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75915-0137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-639-1005
-----------------------------------------------------
Fax | 936-639-1006
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR/OWNER
-----------------------------------------------------
Name | DR. ANDREW J. FERCOWICZ
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 936-639-1005
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | K0743
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------