Healthcare Provider Details

I. General information

NPI: 1730779729
Provider Name (Legal Business Name): THEODORE MANN ANDERSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2021
Last Update Date: 01/22/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MICHIGAN ST NE
GRAND RAPIDS MI
49503-2560
US

IV. Provider business mailing address

225 HASTINGS ST NE APT 211
GRAND RAPIDS MI
49503-1526
US

V. Phone/Fax

Practice location:
  • Phone: 866-989-7999
  • Fax:
Mailing address:
  • Phone: 616-821-4722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: