1093827149 NPI number — CLAYTON MANNING ANDERSON JR. OD

Table of content: RANDALL RENO (NPI 1497620454)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093827149 NPI number — CLAYTON MANNING ANDERSON JR. OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
CLAYTON
Provider Middle Name:
MANNING
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
OD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093827149
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2021 REVERE ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONNELLSVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15425
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-628-3960
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
784 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MT PLEASANT
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15666
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-547-6130
Provider Business Practice Location Address Fax Number:
724-587-4750
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OEG000579 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 410020130 . This is a "PALMETTO GBA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0587150001 . This is a "HEALTHNOW NY INC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 77432 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: PA0579 . This is a "COLE EYEMED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 50552 . This is a "DAVIS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0013245 . This is a "DORAL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 391976 . This is a "NATIONAL VISION ADMINISTR" identifier . This identifiers is of the category "OTHER".
  • Identifier: AN146070 . This is a "PENNSYLVANIA BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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