1285741819 NPI number — MR. GREGORY T ANDERSON LP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285741819 NPI number — MR. GREGORY T ANDERSON LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
GREGORY
Provider Middle Name:
T
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LP
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:
1285741819
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1401 EAST FIRST STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DULUTH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-728-4491
Provider Business Mailing Address Fax Number:
218-728-4404

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
214 W SUPERIOR ST
Provider Second Line Business Practice Location Address:
SKYWALK LEVEL
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55802-1904
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-722-2273
Provider Business Practice Location Address Fax Number:
218-726-1183
Provider Enumeration Date:
08/23/2006

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: 103TC1900X , with the licence number:  LP1457 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X , with the licence number: 7341 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1016110 . This is a "PREFERRED ONE BHP" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 46092 . This is a "OPTUM" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 024 R1LA . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 943752500 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 106621 . This is a "U CARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 62-21313 . This is a "MEDICA / UBH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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