Basic Information
| Provider Information | |||||||||
| NPI: | 1063411601 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAGNET | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | DEAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, PHD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2000 DAN PROCTOR DR | ||||||||
| Address2: | |||||||||
| City: | SAINT MARYS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315583810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125766200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 505 CROSSWIND DR | ||||||||
| Address2: | |||||||||
| City: | FERNANDINA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320342777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126777739 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2005 | ||||||||
| LastUpdateDate: | 06/10/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 060215 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 060215 | GA | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | ME117368 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00609438 | 01 | GA | RR MEDICARE | OTHER | G60215 | 05 | SC | MEDICAID | 220002667A | 05 | GA | MEDICAID |