1942478045 NPI number — ANDREA L LUSK MD LLC

Table of content: (NPI 1942478045)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942478045 NPI number — ANDREA L LUSK MD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANDREA L LUSK MD LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ANDREA L LUSK MD SOLE MBR
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942478045
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/27/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1802 ISLEWORTH CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLDSMAR
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34677-4857
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-868-5875
Provider Business Mailing Address Fax Number:
727-489-9494

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11031 US HIGHWAY 19
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
PORT RICHEY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34668-2213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-868-5875
Provider Business Practice Location Address Fax Number:
727-489-9494
Provider Enumeration Date:
02/12/2008

Additional Information

Authorized Official

Authorized Official Last Name:
LUSK
Authorized Official First Name:
ANDREA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
SOLE OWNER
Authorized Official Telephone Number:
727-868-5875

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  ME 85673 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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