Basic Information
Provider Information | |||||||||
NPI: | 1740279116 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ADAMICH | ||||||||
FirstName: | ANDREW | ||||||||
MiddleName: | R | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | OD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2233 E. MAIN STREET | ||||||||
Address2: | BUSINESS OPTIONS MEDICAL BILLING | ||||||||
City: | MONTROSE | ||||||||
State: | CO | ||||||||
PostalCode: | 81401 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9707650818 | ||||||||
FaxNumber: | 9704978410 | ||||||||
Practice Location | |||||||||
Address1: | 49 MILL STREET | ||||||||
Address2: |   | ||||||||
City: | BAYFIELD | ||||||||
State: | CO | ||||||||
PostalCode: | 81122 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9708842020 | ||||||||
FaxNumber: | 9708842977 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/18/2005 | ||||||||
LastUpdateDate: | 04/07/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2330 | CO | N |   | Eye and Vision Services Providers | Optometrist |   | 152WV0400X | OPT.0002330 | CO | Y |   | Eye and Vision Services Providers | Optometrist | Vision Therapy |
ID Information
ID | Type | State | Issuer | Description | 77857852 | 05 | CO |   | MEDICAID |