Provider Demographics
NPI:1740213610
Name:DEGRUCCIO, ANDREW L (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:L
Last Name:DEGRUCCIO
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 1:9370 CEDAR CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40291
Mailing Address - Country:US
Mailing Address - Phone:502-762-9528
Mailing Address - Fax:502-762-9529
Practice Address - Street 1:9370 CEDAR CENTER WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40291
Practice Address - Country:US
Practice Address - Phone:502-762-9528
Practice Address - Fax:502-762-9529
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY29694207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6798413002OtherCIGNA
KY000000044579OtherANTHEM PROVIDER NUMBER
KYG53033Medicare UPIN
KY1268429Medicare ID - Type Unspecified