Provider Demographics
NPI:1073615431
Name:ADVANCED ANATOMICAL DESIGN LLC
Entity Type:Organization
Organization Name:ADVANCED ANATOMICAL DESIGN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:N
Authorized Official - Last Name:KRATZER
Authorized Official - Suffix:
Authorized Official - Credentials:LO BOCO
Authorized Official - Phone:330-288-0027
Mailing Address - Street 1:375 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-1433
Mailing Address - Country:US
Mailing Address - Phone:330-533-7207
Mailing Address - Fax:330-533-7991
Practice Address - Street 1:300 S STATE ST
Practice Address - Street 2:
Practice Address - City:GIRARD
Practice Address - State:OH
Practice Address - Zip Code:44420-2951
Practice Address - Country:US
Practice Address - Phone:330-288-0027
Practice Address - Fax:330-288-0095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLO0208335E00000X
OHLO0209335E00000X
OHLPED0061335E00000X
OHLP0122335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000230289OtherANTHEM
OH2570918Medicaid
OH2570918Medicaid
OH2570918Medicaid