Provider Demographics
NPI:1629399266
Name:ANDREW MANDERY MD PLASTIC SURGERY LLC
Entity Type:Organization
Organization Name:ANDREW MANDERY MD PLASTIC SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:J
Authorized Official - Last Name:MANDERY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-236-1290
Mailing Address - Street 1:1948 W BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-6078
Mailing Address - Country:US
Mailing Address - Phone:765-236-1290
Mailing Address - Fax:765-236-0420
Practice Address - Street 1:1948 W BOULEVARD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-6078
Practice Address - Country:US
Practice Address - Phone:765-236-1290
Practice Address - Fax:765-236-0420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-17
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010452322086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200101450BMedicaid
IN200101450BMedicaid