Provider Demographics
NPI:1417994997
Name:MATHIS, ANDOLA CHAMBERLAIN (MD)
Entity Type:Individual
Prefix:
First Name:ANDOLA
Middle Name:CHAMBERLAIN
Last Name:MATHIS
Suffix:
Gender:F
Credentials:MD
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:21 MICHIGAN ST NE
Mailing Address - Street 2:SUITE 660
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2528
Mailing Address - Country:US
Mailing Address - Phone:616-451-2993
Mailing Address - Fax:616-451-4393
Practice Address - Street 1:21 MICHIGAN ST NE
Practice Address - Street 2:SUITE 660
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2528
Practice Address - Country:US
Practice Address - Phone:616-451-2993
Practice Address - Fax:616-451-4393
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301074425207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1604113602OtherBCBSM
MI4503527Medicaid
P38640001Medicare PIN
MI1604113602OtherBCBSM