1194042390 NPI number — MR. GERALD FREDERICK ANDERSON PA

Table of content: MR. GERALD FREDERICK ANDERSON PA (NPI 1194042390)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194042390 NPI number — MR. GERALD FREDERICK ANDERSON PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
GERALD
Provider Middle Name:
FREDERICK
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA
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:
1194042390
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4060 HAINES RD
Provider Second Line Business Mailing Address:
#104
Provider Business Mailing Address City Name:
DULUTH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55811-1746
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-250-6435
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4060 HAINES RD
Provider Second Line Business Practice Location Address:
#104
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55811-1746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-250-6435
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/27/2010

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: 363AS0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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