Basic Information
| Provider Information | |||||||||
| NPI: | 1427140755 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MYERS | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9372 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554409372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635330541 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4080 W BROADWAY AVE | ||||||||
| Address2: | 300 | ||||||||
| City: | ROBBINSDALE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554225604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635330541 | ||||||||
| FaxNumber: | 7635331052 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 07/10/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 051515 | OH | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 6287 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 2381515 | 01 | OH | MOLINA MEDICAID | OTHER | 1427140755 | 01 | NPI | OTHER | 650024753 | 01 | RR MEDICARE | OTHER | 7303087000 | 05 | WV | MEDICAID | 000000217253 | 01 | ANTHEM BCBS | OTHER | 353666853-00 | 01 | OH | OH BUREAU WORKERS COMP | OTHER |