Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NR0400X | Rehabilitation Chiropractor | DC 002452L | PA |
NPI | 1437376704 |
---|---|
Provider Name | Dr. Andrew C. Indriso |
First Address | Philadelphia, PA 19102-4533 |
Second Address | Philadelphia, PA 19102-4533 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/04/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2237522000 | IBC PROVIDER # (01) | PA |