Provider Demographics
NPI:1962816678
Name:ANDERSON,ANDREA
Entity Type:Organization
Organization Name:ANDERSON,ANDREA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INDEPENDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-869-0630
Mailing Address - Street 1:1020 SILVERCREST AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44314-2732
Mailing Address - Country:US
Mailing Address - Phone:330-869-0630
Mailing Address - Fax:
Practice Address - Street 1:1020 SILVERCREST AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44314-2732
Practice Address - Country:US
Practice Address - Phone:330-869-0630
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-20
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty