Provider Demographics
NPI:1073598421
Name:ANDERSON, MATTHEW LEE (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:LEE
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CROSBY
Mailing Address - State:MN
Mailing Address - Zip Code:56441-1645
Mailing Address - Country:US
Mailing Address - Phone:218-546-7000
Mailing Address - Fax:218-546-4400
Practice Address - Street 1:320 E MAIN ST
Practice Address - Street 2:CENTRAL LAKES MEDICAL CLINIC PA
Practice Address - City:CROSBY
Practice Address - State:MN
Practice Address - Zip Code:56441-1645
Practice Address - Country:US
Practice Address - Phone:218-546-7000
Practice Address - Fax:218-545-4456
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47166207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN153479300Medicaid
MN153479300Medicaid
MN080014178Medicare ID - Type Unspecified