Provider Demographics
NPI:1831475730
Name:CHAMCZUK, ANDREA JENNIFER (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:JENNIFER
Last Name:CHAMCZUK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1044 BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44504-1006
Mailing Address - Country:US
Mailing Address - Phone:330-743-1928
Mailing Address - Fax:330-744-2110
Practice Address - Street 1:1044 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44504-1006
Practice Address - Country:US
Practice Address - Phone:330-743-1928
Practice Address - Fax:330-744-2110
Is Sole Proprietor?:No
Enumeration Date:2011-10-25
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.141789207T00000X
SC82475207T00000X
NE28190207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL137129Medicaid
MSP01212534OtherRAILROAD MEDICARE
MS01425552Medicaid
MSP01212534OtherRR MCR
MS01425552Medicaid
MS302I44485Medicare PIN
MS302I147057Medicare PIN