1942422514 NPI number — MRS. DANETTE ANDERSON OTD

Table of content: MRS. DANETTE ANDERSON OTD (NPI 1942422514)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942422514 NPI number — MRS. DANETTE ANDERSON OTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
DANETTE
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SUGHROUE
Provider Other First Name:
DANETTE
Provider Other Middle Name:
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1942422514
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/28/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
615 WEST 39TH ST, SUITE A
Provider Second Line Business Mailing Address:
FAMILY PHYSICAL THERAPY & SPORTS CENTER, PC
Provider Business Mailing Address City Name:
KEARNEY
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68845-8049
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-698-2820
Provider Business Mailing Address Fax Number:
308-698-2822

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 WEST 5TH STREET
Provider Second Line Business Practice Location Address:
FAMILY PHYSICAL THERAPY & SPORTS CENTER, PC
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68850
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-324-3700
Provider Business Practice Location Address Fax Number:
308-324-5217
Provider Enumeration Date:
05/03/2007

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: 225X00000X , with the licence number:  1213 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10025290100 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 02334 . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".




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