Provider Demographics
NPI:1457571127
Name:ANDERSON PODIATRY CENTER PC
Entity Type:Organization
Organization Name:ANDERSON PODIATRY CENTER PC
Other - Org Name:POUDRE VALLEY FOOT AND ANKLE CLINIC PC
Other - Org Type:Former Legal Business Name
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 C
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-4368
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 C
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-4368
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:2007-04-26
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
213EP1101X
CO662213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO4800195741OtherRR MEDICARE
CO04013090Medicaid
WYCJ4464OtherRR MEDICARE
WY109240500Medicaid
WY109240500Medicaid
WYW307625Medicare PIN