Provider Demographics
NPI:1083725147
Name:DAVID C. ANDERHOLM, MD, PA
Entity Type:Organization
Organization Name:DAVID C. ANDERHOLM, MD, PA
Other - Org Name:NORTHERN PSYCHIATRIC ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, PRESIDENT, SECRETARY, AND
Authorized Official - Prefix:
Authorized Official - First Name:ELLIOT
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-605-4986
Mailing Address - Street 1:7115 FORTHUN RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425-8597
Mailing Address - Country:US
Mailing Address - Phone:218-454-0090
Mailing Address - Fax:218-454-0091
Practice Address - Street 1:7115 FORTHUN RD
Practice Address - Street 2:SUITE 105
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-8597
Practice Address - Country:US
Practice Address - Phone:218-454-0090
Practice Address - Fax:218-454-0091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN503580500Medicaid
MN55A48ANOtherBCBS
MN55A48ANOtherBCBS