Provider Demographics
NPI:1063865772
Name:MATTHEW ANDERSON, M.D. OBSTETRICS AND GYNECOLOGY, P.A.
Entity Type:Organization
Organization Name:MATTHEW ANDERSON, M.D. OBSTETRICS AND GYNECOLOGY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:W
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:651-653-0062
Mailing Address - Street 1:4465 WHITE BEAR PKWY
Mailing Address - Street 2:SUITE 2
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-7623
Mailing Address - Country:US
Mailing Address - Phone:651-653-0062
Mailing Address - Fax:651-653-0288
Practice Address - Street 1:4465 WHITE BEAR PKWY
Practice Address - Street 2:SUITE 2
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-7623
Practice Address - Country:US
Practice Address - Phone:651-653-0062
Practice Address - Fax:651-653-0288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-18
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46328261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center