1447241989 NPI number — GLENNA R ANDERSEN MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447241989 NPI number — GLENNA R ANDERSEN MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

ANDERSEN

Provider First Name:

GLENNA

Provider Middle Name:

R

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

F

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:

1447241989

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

11/27/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 37174

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

BALTIMORE

Provider Business Mailing Address State Name:

MD

Provider Business Mailing Address Postal Code:

21297-3174

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

571-423-5699

Provider Business Mailing Address Fax Number:

571-423-5698

Provider First Line Business Practice Location Address:

8501 ARLINGTON BLVD

Provider Second Line Business Practice Location Address:

STE 300

Provider Business Practice Location Address City Name:

FAIRFAX

Provider Business Practice Location Address State Name:

VA

Provider Business Practice Location Address Postal Code:

22031-4617

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

703-560-1612

Provider Business Practice Location Address Fax Number:

703-573-0217

Provider Enumeration Date:

11/03/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207V00000X , with the licence number:  0101038435 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 540894297 . This is a "PHCS" identifier . This identifiers is of the category "OTHER".
• Identifier: 0919870001 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
• Identifier: 240947 . This is a "MDIPA/OPTIMUM" identifier . This identifiers is of the category "OTHER".
• Identifier: 468150 . This is a "AETNA HMO" identifier . This identifiers is of the category "OTHER".
• Identifier: 502418 . This is a "NCPPO" identifier . This identifiers is of the category "OTHER".
• Identifier: 6254110 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
• Identifier: 0700360 . This is a "UNHC" identifier . This identifiers is of the category "OTHER".
• Identifier: 34300003 . This is a "BCBS OF DC" identifier . This identifiers is of the category "OTHER".
• Identifier: 440156 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
• Identifier: 540894297 . This is a "GW-ONE HEALTH" identifier . This identifiers is of the category "OTHER".
• Identifier: 4204387 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
• Identifier: 240947 . This is a "ALLIANCE" identifier . This identifiers is of the category "OTHER".
• Identifier: 540894297 . This is a "MAIL HANDLERS" identifier . This identifiers is of the category "OTHER".
• Identifier: 0101038435 . This is a "VA LICENSE" identifier . This identifiers is of the category "OTHER".
• Identifier: 49D0861486 . This is a "CLIA" identifier . This identifiers is of the category "OTHER".