Provider Demographics
NPI:1023235645
Name:ANDRUSS, COLEEN MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:COLEEN
Middle Name:MARIE
Last Name:ANDRUSS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1173 S. 250 W.
Mailing Address - Street 2:SUITE #110 - BLACKRIDGE TERRACE
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770
Mailing Address - Country:US
Mailing Address - Phone:435-986-3800
Mailing Address - Fax:435-986-9018
Practice Address - Street 1:1173 S. 250 W.
Practice Address - Street 2:SUITE #110 - BLACKRIDGE TERRACE
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770
Practice Address - Country:US
Practice Address - Phone:435-986-3800
Practice Address - Fax:435-986-9018
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT983601601205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTF55485Medicare UPIN