Basic Information
| Provider Information | |||||||||
| NPI: | 1467456954 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NOLEWAJKA | ||||||||
| FirstName: | ANDRE | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD; M.CL.SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10570 | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729170570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4793144650 | ||||||||
| FaxNumber: | 4794529459 | ||||||||
| Practice Location | |||||||||
| Address1: | 7001 ROGERS AVE | ||||||||
| Address2: | STE 401 | ||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729034073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4793144650 | ||||||||
| FaxNumber: | 4794529459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2005 | ||||||||
| LastUpdateDate: | 07/01/2013 | ||||||||
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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 | 207RI0011X | R2997 | AR | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 105850001 | 05 | AR | MEDICAID | A002 | 01 | TRICARE | OTHER | 60014634 | 01 | TRAVELERS M/C R/R | OTHER | 100078200A | 05 | OK | MEDICAID | 119173 | 01 | DEPT OF LABOR | OTHER | 14059000040 | 01 | QUALCHOICE | OTHER | 29730300 | 01 | BLACK LUNG | OTHER | 29730300 | 01 | UMWA M/C | OTHER | 53875 | 01 | MEDICARE, ARK BC, FED BC | OTHER |