Provider Demographics
NPI:1912984261
Name:HOTALING, ANDREW JAY (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:JAY
Last Name:HOTALING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 S FIRST AVE
Mailing Address - Street 2:MAGUIRE CENTER 1870
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153
Mailing Address - Country:US
Mailing Address - Phone:708-216-9183
Mailing Address - Fax:708-216-4834
Practice Address - Street 1:2160 S FIRST AVE
Practice Address - Street 2:MAGUIRE CENTER 1870
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153
Practice Address - Country:US
Practice Address - Phone:708-216-9183
Practice Address - Fax:708-216-4834
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-062122207YP0228X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36062122Medicaid
IL699540Medicare ID - Type Unspecified
B44702Medicare UPIN
IL36062122Medicaid