MEDICARE: JOHN ANDERSON ATC, LAT

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	2255A2300X	Athletic Trainer	13	AL

General Provider Information

NPI Number	:	1891812723
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN ANDERSON ATC, LAT

Provider Business Mailing Address
First Line	:	304 MURPHREE ST
Second Line	:
City	:	TROY
State	:	AL
Zip	:	36081-2115
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3212 STADIUM TOWERS
Second Line	:	VETERANS DRIVE - TROY UNIVERSITY
City	:	TROY
State	:	AL
Zip	:	36082-0001
Country	:	US
Telephone Number	:	334-670-3722
Fax Number	:

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

Provider Enumeration Date	:	03/24/2007
Last Update Date	:	07/08/2007

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