Provider Demographics
NPI:1023002268
Name:ANDERS, JASON M (DPT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:M
Last Name:ANDERS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 BRIGHTWATER DR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-8298
Mailing Address - Country:US
Mailing Address - Phone:304-236-3579
Mailing Address - Fax:304-236-4131
Practice Address - Street 1:201 BRIGHTWATER DR
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-8298
Practice Address - Country:US
Practice Address - Phone:304-236-4131
Practice Address - Fax:304-236-4131
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2018-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV001945225100000X
SC8839225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVP00687438OtherRAILROAD MEDICARE
WV2369668OtherMAMSI
WV000019092OtherBCBS
9761231OtherCIGNA
261076OtherCARELINK COVENTRY
WV7302438000Medicaid
9761231OtherCIGNA
WV4146273Medicare PIN