Basic Information
| Provider Information | |||||||||
| NPI: | 1235197088 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OSTRIC | ||||||||
| FirstName: | SRDJAN | ||||||||
| MiddleName: | ANDREI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1316 MERCY DR | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494441835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317399461 | ||||||||
| FaxNumber: | 2317391984 | ||||||||
| Practice Location | |||||||||
| Address1: | 1675 PATRIOT DR | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494447807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317399461 | ||||||||
| FaxNumber: | 2317391984 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 01/28/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0105X | 036107060 | IL | N | Allopathic & Osteopathic Physicians | Surgery | Surgery of the Hand | 208200000X | 036107060 | IL | Y | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 036107060 | 05 | IL | MEDICAID |