Provider Demographics
NPI:1437376704
Name:INDRISO, ANDREW C (DC)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:C
Last Name:INDRISO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-4533
Mailing Address - Country:US
Mailing Address - Phone:215-735-2997
Mailing Address - Fax:215-735-5222
Practice Address - Street 1:1421 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-4533
Practice Address - Country:US
Practice Address - Phone:215-735-2997
Practice Address - Fax:215-735-5222
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC 002452L111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2237522000OtherIBC PROVIDER #