Basic Information
| Provider Information | |||||||||
| NPI: | 1972618775 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCDONALD | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | TAD | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 221 S 6TH ST | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478074214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122423005 | ||||||||
| FaxNumber: | 8122423054 | ||||||||
| Practice Location | |||||||||
| Address1: | 1725 N 5TH ST | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478044010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122423005 | ||||||||
| FaxNumber: | 8122423054 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 04/13/2015 | ||||||||
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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 | 207QS0010X | 36113741 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 2080S0010X | 01062210A | IN | Y | Allopathic & Osteopathic Physicians | Pediatrics | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200826590 | 05 | IN | MEDICAID | N357972 | 05 | IN | MEDICAID | 7037789 | 01 | AETNA | OTHER | P00866719 | 01 | IN | RAILROAD MEDICARE | OTHER | 000000481762 | 01 | ANTHEM | OTHER | 351904269250 | 05 | IN | MEDICAID | 351904269E | 01 | SAGAMORE | OTHER | 5055772 | 01 | CIGNA | OTHER | P00360017 | 01 | RAILROAD MEDICARE PALAMET | OTHER |