1558478107 NPI number — ERIC HENRY ANDERSON PT

Table of content: ERIC HENRY ANDERSON PT (NPI 1558478107)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558478107 NPI number — ERIC HENRY ANDERSON PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
ERIC
Provider Middle Name:
HENRY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1558478107
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1076 W CHANDLER BLVD
Provider Second Line Business Mailing Address:
STE 103
Provider Business Mailing Address City Name:
CHANDLER
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85224-5225
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-821-1997
Provider Business Mailing Address Fax Number:
480-821-1887

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14202 N SCOTTSDALE RD
Provider Second Line Business Practice Location Address:
169
Provider Business Practice Location Address City Name:
SCOTTSDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85254-4077
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-607-9200
Provider Business Practice Location Address Fax Number:
480-607-9207
Provider Enumeration Date:
08/23/2006

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: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 7823 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PT00007654 . This is a "LICENSE #" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 600262 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".