Provider Demographics
NPI:1689692188
Name:ANDREW, MILES BURTON (MD)
Entity Type:Individual
Prefix:
First Name:MILES
Middle Name:BURTON
Last Name:ANDREW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 E CEDAR ST
Mailing Address - Street 2:STE 200
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2057
Mailing Address - Country:US
Mailing Address - Phone:574-335-8700
Mailing Address - Fax:574-335-0760
Practice Address - Street 1:230 E DAY RD
Practice Address - Street 2:SUITE 130
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3408
Practice Address - Country:US
Practice Address - Phone:574-335-7650
Practice Address - Fax:574-335-0736
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040450A207N00000X, 207Q00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100380840AMedicaid
IN100380840Medicaid
IN000000889511OtherBCBS
INM400050229Medicare PIN
IN100380840Medicaid
IN000000889511OtherBCBS
INM400060782Medicare PIN
INM400060782Medicare PIN