1083725147 NPI number — DAVID C. ANDERHOLM, MD, PA

Table of content: (NPI 1083725147)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083725147 NPI number — DAVID C. ANDERHOLM, MD, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVID C. ANDERHOLM, MD, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
NORTHERN PSYCHIATRIC ASSOCIATES
Provider Other Organization Name Type Code:
3
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:
1083725147
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7115 FORTHUN RD
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
BAXTER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56425-8597
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-454-0090
Provider Business Mailing Address Fax Number:
218-454-0091

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7115 FORTHUN RD
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
BAXTER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56425-8597
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-454-0090
Provider Business Practice Location Address Fax Number:
218-454-0091
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RICHELSON
Authorized Official First Name:
ELLIOT
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR, PRESIDENT, SECRETARY, AND
Authorized Official Telephone Number:
904-605-4986

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 503580500 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 55A48AN . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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