Basic Information
| Provider Information | |||||||||
| NPI: | 1780972851 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANDREW R. ADAMICH OD FCOVD INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GRAVITY WORKS VISION DEVELOPMENT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2233 E MAIN ST | ||||||||
| Address2: | BUSINESS OPTIONS MEDICAL BILLING | ||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814013831 | ||||||||
| 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: | 07/11/2011 | ||||||||
| LastUpdateDate: | 10/05/2016 | ||||||||
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| AuthorizedOfficialLastName: | ADAMICH | ||||||||
| AuthorizedOfficialFirstName: | ANDREW | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PROVIDER | ||||||||
| AuthorizedOfficialTelephone: | 9708842020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 59627069 | 05 | CO | MEDICAID |