=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346290590
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANDRUS & ASSOCIATES DERMATOLOGY, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2006
-----------------------------------------------------
Last Update Date | 07/12/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3809 COMPUTER DR SUITE 200
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27609-6518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-782-3782
-----------------------------------------------------
Fax | 919-782-3788
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3809 COMPUTER DR SUITE 200
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27609-6518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-782-3782
-----------------------------------------------------
Fax | 919-782-3788
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | THOMAS ROSS ANDRUS JR.
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 919-782-3782
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 75355
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------