Provider Demographics
NPI:1518210673
Name:ANDERSONTIERNAN, INC
Entity Type:Organization
Organization Name:ANDERSONTIERNAN, INC
Other - Org Name:ADVANCED FOOT & ANKLE CENTERS OF ILLINOIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRECK
Authorized Official - Middle Name:M
Authorized Official - Last Name:TIERNAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:815-553-0990
Mailing Address - Street 1:2980 N BEVERLY GLEN CIR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1726
Mailing Address - Country:US
Mailing Address - Phone:310-474-9809
Mailing Address - Fax:
Practice Address - Street 1:350 HOUBOLT RD
Practice Address - Street 2:SUITE 104
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60431-8305
Practice Address - Country:US
Practice Address - Phone:815-553-0990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ANDERSONTIERNAN, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-25
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site