Healthcare Provider Details

I. General information

NPI: 1891326807
Provider Name (Legal Business Name): MANDERSON ORTHOPAEDIC CLINIC AND JOINT PAIN CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2020
Last Update Date: 02/07/2020
Certification Date: 02/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 VARNUM ST NE STE 207
WASHINGTON DC
20017-2153
US

IV. Provider business mailing address

1140 VARNUM ST NE STE 207
WASHINGTON DC
20017-2153
US

V. Phone/Fax

Practice location:
  • Phone: 202-526-5300
  • Fax: 202-526-6013
Mailing address:
  • Phone: 202-526-5300
  • Fax: 202-526-6013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: EASTON L MANDERSON
Title or Position: PRESIDENT
Credential: MD
Phone: 202-526-5300