Basic Information
| Provider Information | |||||||||
| NPI: | 1285609719 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUMICH | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | IVAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 BALDWIN AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282043109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043761605 | ||||||||
| FaxNumber: | 7043358448 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 BALDWIN AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282043109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043761605 | ||||||||
| FaxNumber: | 7043358448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2006 | ||||||||
| LastUpdateDate: | 12/08/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 2005-00441 | NC | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 5900887 | 05 | NC | MEDICAID | N0044K | 05 | SC | MEDICAID |