Basic Information
| Provider Information | |||||||||
| NPI: | 1861477903 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LODER | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | SLIFER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HELMICH | ||||||||
| OtherFirstName: | ANDREA | ||||||||
| OtherMiddleName: | SLIFER | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1005 MAR WALT DR | ||||||||
| Address2: | PEDIATRIC DEPARTMENT | ||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325476707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508638203 | ||||||||
| FaxNumber: | 8508620977 | ||||||||
| Practice Location | |||||||||
| Address1: | 965 S BAILEY AVE STE 2-4 | ||||||||
| Address2: | |||||||||
| City: | SOUTH HAVEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490906743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696392777 | ||||||||
| FaxNumber: | 2696392776 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2005 | ||||||||
| LastUpdateDate: | 10/06/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME70335 | FL | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 4301116417 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 379588800 | 05 | FL | MEDICAID | 28977 | 01 | FL | BCBSFL | OTHER |