Provider Demographics
NPI:1316905482
Name:ANDERSON, JOEL FORDYCE (PT)
Entity type:Individual
Prefix:MR
First Name:JOEL
Middle Name:FORDYCE
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 300
Mailing Address - Street 2:
Mailing Address - City:SHELL LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54871-0300
Mailing Address - Country:US
Mailing Address - Phone:715-468-7833
Mailing Address - Fax:715-468-7303
Practice Address - Street 1:113 4TH AVE
Practice Address - Street 2:
Practice Address - City:SHELL LAKE
Practice Address - State:WI
Practice Address - Zip Code:54871-0300
Practice Address - Country:US
Practice Address - Phone:715-468-7833
Practice Address - Fax:715-468-7303
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0530225100000X
WI11290-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD101596Medicare PIN
SDS3802Medicare ID - Type Unspecified