Provider Demographics
NPI:1821248477
Name:JOHN B ANDELIN MD PC
Entity Type:Organization
Organization Name:JOHN B ANDELIN MD PC
Other - Org Name:PATHOLOGY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:B
Authorized Official - Last Name:ANDELIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:701-572-3800
Mailing Address - Street 1:201 2ND AVE W
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-5920
Mailing Address - Country:US
Mailing Address - Phone:701-572-3800
Mailing Address - Fax:701-774-7402
Practice Address - Street 1:1301 15TH AVE W
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-3821
Practice Address - Country:US
Practice Address - Phone:701-572-3800
Practice Address - Fax:701-774-7402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-19
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5162207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTAPPLIED FORMedicaid
NDAPPLIED FORMedicaid
NDAPPLIED FORMedicare PIN
MTAPPLIED FORMedicaid