MEDICARE: ANDREW MARCUS ROSENDAHL IDC

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	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1538355219
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREW MARCUS ROSENDAHL IDC

Provider Business Mailing Address
First Line	:	1912 FALCON DR
Second Line	:
City	:	PORTLAND
State	:	TX
Zip	:	78374-2715
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1912 FALCON DRIVE
Second Line	:
City	:	PORTLAND
State	:	TX
Zip	:	78374
Country	:	US
Telephone Number	:	361-563-9720
Fax Number	:

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

Provider Enumeration Date	:	09/17/2007
Last Update Date	:	09/17/2007

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