Basic Information
| Provider Information | |||||||||
| NPI: | 1073893822 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDOLINA | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | ANTHONY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2379 | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411052379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064086200 | ||||||||
| FaxNumber: | 6064086612 | ||||||||
| Practice Location | |||||||||
| Address1: | 617 23RD ST STE 105 | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411012890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064087500 | ||||||||
| FaxNumber: | 6064086600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2011 | ||||||||
| LastUpdateDate: | 11/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | 34.013576 | OH | N | Allopathic & Osteopathic Physicians | Plastic Surgery | 208600000X | 0300434 | NY | N | Allopathic & Osteopathic Physicians | Surgery | 208200000X | 04178 | KY | Y | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 7100508950 | 05 | KY | MEDICAID |