Basic Information
| Provider Information | |||||||||
| NPI: | 1962460964 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MERNITZ | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SIGNORINO | ||||||||
| OtherFirstName: | ANDREA | ||||||||
| OtherMiddleName: | MERNITZ | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4001 W GOELLER BLVD STE A | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472018309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123753330 | ||||||||
| FaxNumber: | 8123753329 | ||||||||
| Practice Location | |||||||||
| Address1: | 4001 W GOELLER BLVD STE A | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472018309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123753330 | ||||||||
| FaxNumber: | 8123753329 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 10/28/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 1051166 | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000089944 | 01 | IN | BLUE CROSS ANTHEM | OTHER | 1051166 | 01 | IN | IN MEDICAL LICENSE | OTHER | 000000984082 | 01 | IN | ANTHEM PIN | OTHER | 080141548 | 01 | IN | MEDICARE RAILROAD | OTHER | 200229670A | 05 | IN | MEDICAID |