Provider Demographics
NPI:1073730149
Name:ANDERSON, STEPHANIE S (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:S
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7101 JAHNKE RD
Mailing Address - Street 2:CJW MEDICAL CENTER
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23225-4017
Mailing Address - Country:US
Mailing Address - Phone:804-228-6532
Mailing Address - Fax:804-308-8031
Practice Address - Street 1:7101 JAHNKE RD
Practice Address - Street 2:CJW MEDICAL CENTER
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23225-4017
Practice Address - Country:US
Practice Address - Phone:804-228-6532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101241558207P00000X
OH35089032207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1073730149Medicaid
VA014093V68Medicare PIN
VA014094V21Medicare PIN
VA1073730149Medicaid