1114125655 NPI number — MR. BENJAMIN EDWARD ANDERSON P.T.

Table of content: MR. BENJAMIN EDWARD ANDERSON P.T. (NPI 1114125655)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114125655 NPI number — MR. BENJAMIN EDWARD ANDERSON P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
BENJAMIN
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
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:
1114125655
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3400 CRAWFORD DR SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37323-0216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-504-0132
Provider Business Mailing Address Fax Number:
423-570-8001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7937 RHEA COUNTY HWY
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
DAYTON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37321-5990
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-570-0800
Provider Business Practice Location Address Fax Number:
423-570-8001
Provider Enumeration Date:
07/06/2007

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: 225100000X , with the licence number:  6612 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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