Provider Demographics
NPI:1528181146
Name:ANDRESS, TIMOTHY (CRNA)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:ANDRESS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CAMPUS DR
Mailing Address - Street 2:
Mailing Address - City:HANCOCK
Mailing Address - State:MI
Mailing Address - Zip Code:49930-1569
Mailing Address - Country:US
Mailing Address - Phone:906-483-1356
Mailing Address - Fax:906-483-1320
Practice Address - Street 1:500 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:HANCOCK
Practice Address - State:MI
Practice Address - Zip Code:49930-1569
Practice Address - Country:US
Practice Address - Phone:906-483-1356
Practice Address - Fax:906-483-1320
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI036298367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C16002OtherMEDICARE GROUP
MI430041684OtherMEDICARE RAILROAD
MI0829560001OtherMEDICARE DME
MI101616429Medicaid
MITA036298OtherBLUE CROSS STATE ID
MI0C16002OtherMEDICARE GROUP