MEDICARE: RODNEY KENT VAN ANDEL M.D.

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	L7909	TX
2	207QS0010X	Sports Medicine (Family Medicine) Physician	L7909	TX

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00165779	OTHER	TX	RAILROAD MEDICARE

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	138771100	OTHER	TX	FIRSTCARE SOUTHWEST
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	8K1901	OTHER	TX	TEXAS BCBS
5	TIN PLUS 001	OTHER	TX	TRICARE CANTON LOCATION
6	TIN PLUS 002	OTHER	TX	TRICARE LAKE PALESTINE LOCATION
7	TIN PLUS 028	OTHER	TX	TRICARE
8	PP10013213	OTHER	TX	TEXAS WORKERS COMP
9	129375	OTHER	TX	CHIPS
10	8V5495	OTHER	TX	BCBS
11	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1154326544
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RODNEY KENT VAN ANDEL M.D.

Provider Business Mailing Address
First Line	:	PO BOX 5500
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75712-5500
Country	:	US
Telephone Number	:	903-324-6450
Fax Number	:	903-593-7569

Provider Business Practice Location Address
First Line	:	3203 S MAIN ST
Second Line	:
City	:	LINDALE
State	:	TX
Zip	:	75771-7727
Country	:	US
Telephone Number	:	903-266-4000
Fax Number	:	903-882-7751

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2005
Last Update Date	:	05/14/2014

3203 S MAIN ST
LINDALE, TX
75771-7727

Practice Phone: 903-882-0991
Practice Fax: 903-882-7751

3202 S MAIN ST
LINDALE, TX
75771-7727