MEDICARE: DR. ANDREA LILLY DIEVENDORF DC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	X0108561	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	2601222001	OTHER	BSNENY
2	7016671	OTHER	AETNA
3	NY23902	OTHER	MVP

General Provider Information

NPI Number	:	1225012800
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANDREA LILLY DIEVENDORF DC

Provider Business Mailing Address
First Line	:	2 CHELSEA PL
Second Line	:
City	:	CLIFTON PARK
State	:	NY
Zip	:	12065-3227
Country	:	US
Telephone Number	:	518-373-6545
Fax Number	:

Provider Business Practice Location Address
First Line	:	2 CHELSEA PL
Second Line	:
City	:	CLIFTON PARK
State	:	NY
Zip	:	12065-3227
Country	:	US
Telephone Number	:	518-373-6545
Fax Number	:

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

Provider Enumeration Date	:	12/06/2005
Last Update Date	:	08/25/2016

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