Provider Demographics
NPI:1093943656
Name:EICKENBROCK, ANDREA M (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:M
Last Name:EICKENBROCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:MARIE
Other - Last Name:FELTMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2401 DEMERS AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4032
Mailing Address - Country:US
Mailing Address - Phone:701-780-1891
Mailing Address - Fax:
Practice Address - Street 1:1380 S COLUMBIA RD - ALTRU FAMILY MEDICINE CENTER
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4059
Practice Address - Country:US
Practice Address - Phone:701-795-2000
Practice Address - Fax:701-795-2260
Is Sole Proprietor?:No
Enumeration Date:2009-06-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR71437207V00000X
ND12801207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND18826Medicaid
ND18826Medicaid