Basic Information
| Provider Information | |||||||||
| NPI: | 1730136672 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | ADINA-MARIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 549 | ||||||||
| Address2: | |||||||||
| City: | IRON MOUNTAIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498010549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067741313 | ||||||||
| FaxNumber: | 9067765639 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 W H ST | ||||||||
| Address2: | |||||||||
| City: | IRON MOUNTAIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498014608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067765940 | ||||||||
| FaxNumber: | 9067792586 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 02/21/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 5901002125 | MI | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 4881074 | 05 | MI | MEDICAID | 5220021 | 01 | MI | BCBS OF MI | OTHER | P00958672 | 01 | MI | RR MEDICARE | OTHER | 43241400 | 05 | WI | MEDICAID |