1710919501 NPI number — EASTON L. MANDERSON, M.D., F.A.C.S., PC

Table of content: (NPI 1710919501)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710919501 NPI number — EASTON L. MANDERSON, M.D., F.A.C.S., PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTON L. MANDERSON, M.D., F.A.C.S., PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MANDERSON ORTHOPAEDIC CLINIC AND JOINT PAIN CENTER
Provider Other Organization Name Type Code:
3
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:
1710919501
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1140 VARNUM ST NE STE 108
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WASHINGTON
Provider Business Mailing Address State Name:
DC
Provider Business Mailing Address Postal Code:
20017-2152
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
202-526-5300
Provider Business Mailing Address Fax Number:
202-526-6013

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1140 VARNUM ST NE STE 108
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
DC
Provider Business Practice Location Address Postal Code:
20017-2152
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
202-526-5300
Provider Business Practice Location Address Fax Number:
202-526-6013
Provider Enumeration Date:
07/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MANDERSON
Authorized Official First Name:
EASTON
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
202-526-5300

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: F921 . This is a "CAREFIRST" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 147572700 . This is a "DEPT OF LABOR" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 60184300 . This is a "AMERIHEALTH DC MEDICAID" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: DE6844 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 021189900 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4053124 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".




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