Provider Demographics
NPI:1679751754
Name:BRANDYWINE VALLEY NEUROSURGERY AND SPINE LLC
Entity Type:Organization
Organization Name:BRANDYWINE VALLEY NEUROSURGERY AND SPINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:FREESE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:610-384-0482
Mailing Address - Street 1:213 REECEVILLE RD
Mailing Address - Street 2:STE 33
Mailing Address - City:COATESVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19320-1528
Mailing Address - Country:US
Mailing Address - Phone:610-384-0482
Mailing Address - Fax:610-384-0485
Practice Address - Street 1:213 REECEVILLE RD
Practice Address - Street 2:STE 33
Practice Address - City:COATESVILLE
Practice Address - State:PA
Practice Address - Zip Code:19320-1528
Practice Address - Country:US
Practice Address - Phone:610-384-0482
Practice Address - Fax:610-384-0485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD048535L207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2017841OtherHIGHMARK
PA3432945000OtherINDEPENDENCE BLUE CROSS