1265453096 NPI number — SANDRA M ANDERSON AU.D.CCC-A

Table of content: SANDRA M ANDERSON AU.D.CCC-A (NPI 1265453096)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265453096 NPI number — SANDRA M ANDERSON AU.D.CCC-A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
SANDRA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AU.D.CCC-A
Provider Gender Code:
F

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:
1265453096
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/25/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1701 WESTCHESTER DR
Provider Second Line Business Mailing Address:
STE 850
Provider Business Mailing Address City Name:
HIGH POINT
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27262-7254
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-802-2400
Provider Business Mailing Address Fax Number:
336-802-2001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
624 QUAKER LN
Provider Second Line Business Practice Location Address:
SUITE 208C
Provider Business Practice Location Address City Name:
HIGH POINT
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27262-3832
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-802-2085
Provider Business Practice Location Address Fax Number:
336-802-2086
Provider Enumeration Date:
07/21/2006

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: 231H00000X , with the licence number:  4855 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3404192 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 640003894 . This is a "RR MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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