Provider Demographics
NPI:1619149838
Name:PAUL B ANDELIN MD PC
Entity Type:Organization
Organization Name:PAUL B ANDELIN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:B
Authorized Official - Last Name:ANDELIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-678-4022
Mailing Address - Street 1:1937 W CARDINAL LN
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:MO
Mailing Address - Zip Code:65605-1977
Mailing Address - Country:US
Mailing Address - Phone:417-678-4022
Mailing Address - Fax:417-678-4028
Practice Address - Street 1:1937 W CARDINAL LN
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:MO
Practice Address - Zip Code:65605-1977
Practice Address - Country:US
Practice Address - Phone:417-678-4022
Practice Address - Fax:417-678-4028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR3M76207V00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOE60486Medicare UPIN