Basic Information
Provider Information | |||||||||
NPI: | 1295752723 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ANDRIOLE | ||||||||
FirstName: | GERALD | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6201 GREENLEIGH AVE | ||||||||
Address2: |   | ||||||||
City: | MIDDLE RIVER | ||||||||
State: | MD | ||||||||
PostalCode: | 212202004 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4921 PARKVIEW PL | ||||||||
Address2: | DIV SURG UROLOGY, STE 11C | ||||||||
City: | SAINT LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631101032 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3143628200 | ||||||||
FaxNumber: | 3144545244 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/17/2006 | ||||||||
LastUpdateDate: | 03/09/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/09/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | R8E23 | MO | N |   | Allopathic & Osteopathic Physicians | Urology |   | 208800000X | D30346 | MD | Y |   | Allopathic & Osteopathic Physicians | Urology |   |
ID Information
ID | Type | State | Issuer | Description | 202124103 | 05 | MO |   | MEDICAID | D30346 | 01 | MD | MD LICENSE | OTHER |