Provider Demographics
NPI:1245288745
Name:ANDERSON PROSTHETICS & ORTHOTICS, LLC
Entity type:Organization
Organization Name:ANDERSON PROSTHETICS & ORTHOTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CORCORAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:CPO
Authorized Official - Phone:301-585-5347
Mailing Address - Street 1:1113 N FANT ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-4819
Mailing Address - Country:US
Mailing Address - Phone:864-225-1683
Mailing Address - Fax:864-231-7374
Practice Address - Street 1:1113 N FANT ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-4819
Practice Address - Country:US
Practice Address - Phone:864-225-1683
Practice Address - Fax:864-231-7374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE1943Medicaid
GA00926428AMedicaid
SCDE1943Medicaid
GA00926428AMedicaid