Provider Demographics
NPI:1134240880
Name:ANDREW M AGOSTA MD PC
Entity type:Organization
Organization Name:ANDREW M AGOSTA MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:M
Authorized Official - Last Name:AGOSTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-263-3545
Mailing Address - Street 1:51221 SCHOENHERR RD
Mailing Address - Street 2:STE 201
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-2708
Mailing Address - Country:US
Mailing Address - Phone:586-263-3545
Mailing Address - Fax:586-254-3136
Practice Address - Street 1:51221 SCHOENHERR RD
Practice Address - Street 2:STE 201
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-2708
Practice Address - Country:US
Practice Address - Phone:586-263-3545
Practice Address - Fax:586-254-3136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1605094691OtherBLUE CROSS BLUE SHIELD
MI1002931963Medicaid
MI=========OtherTRICARE
MI0M35160Medicare PIN
MI1605094691OtherBLUE CROSS BLUE SHIELD