=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780653816
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS ROSS ANDRUS JR. M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2006
-----------------------------------------------------
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 |
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 26079
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------