Basic Information
| Provider Information | |||||||||
| NPI: | 1093943656 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EICKENBROCK | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FELTMAN | ||||||||
| OtherFirstName: | ANDREA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2401 DEMERS AVE | ||||||||
| Address2: | |||||||||
| City: | GRAND FORKS | ||||||||
| State: | ND | ||||||||
| PostalCode: | 582014032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017801891 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1380 S COLUMBIA RD - ALTRU FAMILY MEDICINE CENTER | ||||||||
| Address2: | |||||||||
| City: | GRAND FORKS | ||||||||
| State: | ND | ||||||||
| PostalCode: | 582014059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017952000 | ||||||||
| FaxNumber: | 7017952260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2009 | ||||||||
| LastUpdateDate: | 01/22/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | R71437 | AZ | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 12801 | ND | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 18826 | 05 | ND | MEDICAID |