Provider Demographics
NPI:1336300086
Name:TEDROS ANDOM, MD LLC
Entity Type:Organization
Organization Name:TEDROS ANDOM, MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TEDROS
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-323-2690
Mailing Address - Street 1:2624 LEXINGTON AVE
Mailing Address - Street 2:SUITE 340
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45505-2607
Mailing Address - Country:US
Mailing Address - Phone:937-688-1588
Mailing Address - Fax:
Practice Address - Street 1:2624 LEXINGTON AVE
Practice Address - Street 2:SUITE 340
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45505-2607
Practice Address - Country:US
Practice Address - Phone:937-688-1588
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-24
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-091693208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2854326Medicaid
OH9377541Medicare PIN