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NPI Code Detail

MEDICARE: CLYDE ANDERSON III

MEDICARE: CLYDE ANDERSON III
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12255A2300XAthletic Trainer
2390200000XStudent in an Organized Health Care Education/Training Program

General Provider Information

NPI Number : 1285181222
Entity Type Code : Individual
Provider Name (Legal Business Name) : CLYDE ANDERSON III
Provider Business Mailing Address
First Line : 2103 CAMPUS VILLAGE AVE APT 3
Second Line :
City : SAGINAW
State : MI
Zip : 48604-8805
Country : US
Telephone Number : 810-965-4642
Fax Number :
Provider Business Practice Location Address
First Line : 2103 CAMPUS VILLAGE AVE APT 3
Second Line :
City : SAGINAW
State : MI
Zip : 48604-8805
Country : US
Telephone Number : 810-965-4642
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/07/2016
Last Update Date : 09/07/2016

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