Basic Information
| Provider Information | |||||||||
| NPI: | 1639102460 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDRES | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 802 N. RIVERSIDE RD., | ||||||||
| Address2: | SUITE G 50 | ||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 645072553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8166714888 | ||||||||
| FaxNumber: | 8166714890 | ||||||||
| Practice Location | |||||||||
| Address1: | 802 N. RIVERSIDE RD., | ||||||||
| Address2: | SUITE G 50 | ||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 645072553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8166714888 | ||||||||
| FaxNumber: | 8166714890 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 02/28/2011 | ||||||||
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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 | 208600000X | R4278 | MO | Y | Allopathic & Osteopathic Physicians | Surgery | 2086S0127X | R4278 | MO | N | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 2086S0129X | R4278 | MO | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 10001262101 | 01 | MO | COMMUNITY HEALTH PLAN | OTHER | 100130870B | 05 | KS | MEDICAID | P00193414 | 01 | MO | RR MEDICARE | OTHER | 200374411 | 05 | MO | MEDICAID |