Provider Demographics
NPI:1588623276
Name:ANDRIES, KATHLEEN M (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:ANDRIES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4025 HEALTH PARK LN
Mailing Address - Street 2:CARING CIRCLE
Mailing Address - City:ST JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085
Mailing Address - Country:US
Mailing Address - Phone:269-429-7100
Mailing Address - Fax:269-429-1959
Practice Address - Street 1:4025 HEALTH PARK LN
Practice Address - Street 2:CARING CIRCLE
Practice Address - City:ST JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085
Practice Address - Country:US
Practice Address - Phone:269-429-7100
Practice Address - Fax:269-429-1959
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2017-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKA036485207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI110203216OtherRAIL ROAD MEDICARE
MI0A110280OtherBCBS
MI110203216OtherRAIL ROAD MEDICARE
MIB45820Medicare UPIN
MIA16056056Medicare PIN