Provider Demographics
NPI:1093759391
Name:ANDRZEJEWSKI, JERZY JAN
Entity Type:Individual
Prefix:
First Name:JERZY
Middle Name:JAN
Last Name:ANDRZEJEWSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 MAPLE LN
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806-3768
Mailing Address - Country:US
Mailing Address - Phone:715-685-7500
Mailing Address - Fax:
Practice Address - Street 1:TWIN PORTS OUTPATIENT CLINIC
Practice Address - Street 2:3520 TOWER AVENUE
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880
Practice Address - Country:US
Practice Address - Phone:715-392-9711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45598-020207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34423600Medicaid
WI34423600Medicaid