Basic Information
| Provider Information | |||||||||
| NPI: | 1154326544 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAN ANDEL | ||||||||
| FirstName: | RODNEY | ||||||||
| MiddleName: | KENT | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5500 | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757125500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246450 | ||||||||
| FaxNumber: | 9035937569 | ||||||||
| Practice Location | |||||||||
| Address1: | 3203 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LINDALE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757717727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9032664000 | ||||||||
| FaxNumber: | 9038827751 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2005 | ||||||||
| LastUpdateDate: | 05/14/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | L7909 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | L7909 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 138771100 | 01 | TX | FIRSTCARE SOUTHWEST | OTHER | P00165779 | 01 | TX | RAILROAD MEDICARE | OTHER | 166412003 | 05 | TX | MEDICAID | 8K1901 | 01 | TX | TEXAS BCBS | OTHER | TIN PLUS 001 | 01 | TX | TRICARE CANTON LOCATION | OTHER | TIN PLUS 002 | 01 | TX | TRICARE LAKE PALESTINE LOCATION | OTHER | TIN PLUS 028 | 01 | TX | TRICARE | OTHER | PP10013213 | 01 | TX | TEXAS WORKERS COMP | OTHER | 129375 | 01 | TX | CHIPS | OTHER | 8V5495 | 01 | TX | BCBS | OTHER | 166412001 | 05 | TX | MEDICAID |