Basic Information
| Provider Information | |||||||||
| NPI: | 1992745715 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDELMAN | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7693 | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805370693 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 106 BLANCA AVE | ||||||||
| Address2: | |||||||||
| City: | ALAMOSA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 811012340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8776624044 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 10/04/2007 | ||||||||
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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 | 174400000X | 40629 | CO | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | P00061125 | 01 | CO | RAILROAD MEDICARE | OTHER | 35007508 | 05 | CO | MEDICAID |