Provider Demographics
NPI:1588113492
Name:ANDREADIS, ANTHONY JOSEPH (ATC)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:JOSEPH
Last Name:ANDREADIS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 WIGWAM HOLLOW RD
Mailing Address - Street 2:APT 1
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-4152
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:908 WIGWAM HOLLOW RD APT 1
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-4153
Practice Address - Country:US
Practice Address - Phone:973-223-4863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-04
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.003868246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other