MEDICARE: DR. BRENT J. VAN ANDEL M.D.

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	207Q00000X	Family Medicine Physician	2004-0159	NM

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NMA100443	OTHER	NM	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770576134
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRENT J. VAN ANDEL M.D.

Provider Business Mailing Address
First Line	:	PO BOX 158
Second Line	:	EL CENTRO FAMILY HEALTH
City	:	ESPANOLA
State	:	NM
Zip	:	87532-0158
Country	:	US
Telephone Number	:	505-753-7218
Fax Number	:	505-753-5815

Provider Business Practice Location Address
First Line	:	711 BOND ST
Second Line	:	EL CENTRO FAMILY HEALTH BOND CLINIC
City	:	ESPANOLA
State	:	NM
Zip	:	87532-2729
Country	:	US
Telephone Number	:	505-753-9503
Fax Number	:	505-747-1004

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

Provider Enumeration Date	:	08/31/2005
Last Update Date	:	07/01/2013

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