Basic Information
| Provider Information | |||||||||
| NPI: | 1164487104 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOMA | ||||||||
| FirstName: | ANDREW | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 812 E JOLLY RD | ||||||||
| Address2: | STE 210 | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489106818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173468410 | ||||||||
| FaxNumber: | 5173468291 | ||||||||
| Practice Location | |||||||||
| Address1: | 5303 S CEDAR ST | ||||||||
| Address2: | STE 110 | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489113800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173468026 | ||||||||
| FaxNumber: | 5173468291 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2006 | ||||||||
| LastUpdateDate: | 09/02/2010 | ||||||||
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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 | 2084P0800X | 4301042360 | MI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 101001365 | 05 | MI | MEDICAID |