Basic Information
| Provider Information | |||||||||
| NPI: | 1942664784 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GENTILE | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | LESLIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 710 N NILES AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466171924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746471610 | ||||||||
| FaxNumber: | 5742376069 | ||||||||
| Practice Location | |||||||||
| Address1: | 1753 FULTON ST | ||||||||
| Address2: | |||||||||
| City: | ELKHART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465141927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742939448 | ||||||||
| FaxNumber: | 5742939480 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2016 | ||||||||
| LastUpdateDate: | 08/31/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 01085704A | IN | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 236040366 | 01 | IN | MEDICARE PTAN | OTHER | 300050491 | 05 | IN | MEDICAID | 08333075 | 05 | MS | MEDICAID | 213362795 | 05 | AR | MEDICAID |