Basic Information
| Provider Information | |||||||||
| NPI: | 1578637245 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDOH | ||||||||
| FirstName: | HENRY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 761 45TH AVE | ||||||||
| Address2: | STE. 103 | ||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463212893 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199223002 | ||||||||
| FaxNumber: | 2199223003 | ||||||||
| Practice Location | |||||||||
| Address1: | 757 45TH AVE | ||||||||
| Address2: | STE. 201 | ||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463212911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199342461 | ||||||||
| FaxNumber: | 2199342478 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 05/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | 36-083429 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207RI0200X | 01042402A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 110108462 | 01 | IL | RAILROAD MEDICARE | OTHER | 0001606805 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER | 0004542266 | 01 | IL | AETNA | OTHER | 200009960B | 05 | IN | MEDICAID |