Provider Demographics
NPI:1497996888
Name:DR. ANDY'S FAMILY PRACTICE , PLLC
Entity Type:Organization
Organization Name:DR. ANDY'S FAMILY PRACTICE , PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VASUGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANANDARAJ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-269-7777
Mailing Address - Street 1:PO BOX 1198
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:AR
Mailing Address - Zip Code:72560-1198
Mailing Address - Country:US
Mailing Address - Phone:870-269-7777
Mailing Address - Fax:
Practice Address - Street 1:1809 OZARKA COLLEGE DRIVE
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:AR
Practice Address - Zip Code:72560
Practice Address - Country:US
Practice Address - Phone:870-269-7777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-13
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR161503001Medicaid
AR5N567Medicare PIN
ARI57010Medicare UPIN