Provider Demographics
NPI:1013116938
Name:FOOT SURGERY CENTER OF NORTHERN COLORADO LLC
Entity Type:Organization
Organization Name:FOOT SURGERY CENTER OF NORTHERN COLORADO LLC
Other - Org Name:ANDERSON PODIATRY CENTER/SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:970-484-4620
Mailing Address - Street 1:1355 RIVERSIDE AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524
Mailing Address - Country:US
Mailing Address - Phone:970-484-4620
Mailing Address - Fax:
Practice Address - Street 1:1355 RIVERSIDE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524
Practice Address - Country:US
Practice Address - Phone:970-484-4620
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-11
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO662261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO490003559OtherMEDICARE - RR
CO04510368Medicaid
WY114239900Medicaid
COCA61043Medicare PIN