Provider Demographics
NPI:1700066529
Name:KIRK G ANDRUS MD
Entity Type:Organization
Organization Name:KIRK G ANDRUS MD
Other - Org Name:KELSEYVILLE FAMILY PRACTICE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:G
Authorized Official - Last Name:ANDRUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-279-2204
Mailing Address - Street 1:4135 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KELSEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95451-8941
Mailing Address - Country:US
Mailing Address - Phone:707-279-2204
Mailing Address - Fax:707-279-2832
Practice Address - Street 1:4135 MAIN ST
Practice Address - Street 2:
Practice Address - City:KELSEYVILLE
Practice Address - State:CA
Practice Address - Zip Code:95451-8941
Practice Address - Country:US
Practice Address - Phone:707-279-2004
Practice Address - Fax:707-279-2832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-08
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG34543207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G345432Medicare PIN