Basic Information
| Provider Information | |||||||||
| NPI: | 1205839180 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ASSIAMAH | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 105 WHITLOCK CT | ||||||||
| Address2: | |||||||||
| City: | MANALAPAN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077267936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7323108764 | ||||||||
| FaxNumber: | 7328660998 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 US 130 NORTH | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | CINNAMINSON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8568299345 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 25MA07733000 | NJ | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0048402 | 05 | NJ | MEDICAID |