Provider Demographics
NPI:1124196936
Name:ANDRITSIS, BRENDA M (MD)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:M
Last Name:ANDRITSIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HENRY FORD HEALTH SYSTEM
Mailing Address - Street 2:2825 LIVERNOIS
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083
Mailing Address - Country:US
Mailing Address - Phone:248-680-6000
Mailing Address - Fax:248-680-6068
Practice Address - Street 1:HENRY FORD HEALTH SYSTEM
Practice Address - Street 2:2825 LIVERNOIS
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083
Practice Address - Country:US
Practice Address - Phone:248-680-6000
Practice Address - Fax:248-680-6068
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301054934207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI293857010Medicaid
BA054934OtherCHAMPUS-CHAMPUS
080H262390OtherBLUE CROSS-BLUE CROSS
BA054934OtherCOMMERCIAL-COMMERCIAL NUMBER
F39075Medicare UPIN
0H26239067Medicare ID - Type Unspecified