1215014592 NPI number — RICHARD O ANDERSON MD

Table of content: RICHARD O ANDERSON MD (NPI 1215014592)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215014592 NPI number — RICHARD O ANDERSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
RICHARD
Provider Middle Name:
O
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215014592
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3100 W LAKE ST
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55416-4527
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-925-6033
Provider Business Mailing Address Fax Number:
612-925-8496

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3100 W LAKE ST
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55416-4527
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-925-6033
Provider Business Practice Location Address Fax Number:
612-925-8496
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  15279 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: HP15795 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 285583600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 321G7AN . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1552260 . This is a "UBH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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