MEDICARE: DR. AMY SANDERSON O.D.

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
1	152W00000X	Optometrist	S-997-TA-564	AL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	102G700010	OTHER		PTAN FOR ADVANCED EYECARE OF MADISON FOR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	102G700010	OTHER		PTAN FOR ADVANCED EYECARE OF MADISON

General Provider Information

NPI Number	:	1669477824
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AMY SANDERSON O.D.

Provider Business Mailing Address
First Line	:	102 INTERCOM DRIVE
Second Line	:
City	:	MADISON
State	:	AL
Zip	:	35758-2638
Country	:	US
Telephone Number	:	256-772-2929
Fax Number	:	256-772-2928

Provider Business Practice Location Address
First Line	:	102 INTERCOM DRIVE
Second Line	:
City	:	MADISON
State	:	AL
Zip	:	35758-2638
Country	:	US
Telephone Number	:	256-772-2929
Fax Number	:	256-772-2928

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2005
Last Update Date	:	05/07/2012

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