1356351688 NPI number — JERRY M ANDERSON JR. MD

Table of content: JERRY M ANDERSON JR. MD (NPI 1356351688)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356351688 NPI number — JERRY M ANDERSON JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
JERRY
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
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:
1356351688
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/16/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1201 TERRY AVE FL 8
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98101-2735
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-287-6300
Provider Business Mailing Address Fax Number:
206-341-1250

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 TERRY AVE FL 8
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98101-2735
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-287-6300
Provider Business Practice Location Address Fax Number:
206-341-1250
Provider Enumeration Date:
08/09/2006

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: 207V00000X , with the licence number:  L5224 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: MD60481560 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2044576 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 161225101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8F8791 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 133275100 . This is a "FIRST CARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".