Provider Demographics
NPI:1851363733
Name:ALLYN, ANDREA L (MD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:L
Last Name:ALLYN
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:PO BOX 601082
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1082
Mailing Address - Country:US
Mailing Address - Phone:864-885-7989
Mailing Address - Fax:864-885-7867
Practice Address - Street 1:10110 CLEMSON BLVD
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-0812
Practice Address - Country:US
Practice Address - Phone:864-482-0500
Practice Address - Fax:864-482-0505
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC30703207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA2717OtherMEDICARE PTAN
GA000222285EMedicaid
SC1851363733Medicaid
SC1851363733Medicaid
SC8768Medicare PIN
GA000222285EMedicaid