Provider Demographics
NPI:1093759045
Name:ANDERSON, RICHARD THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:THOMAS
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 1:5158 LAKESHORE RD
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-3115
Mailing Address - Country:US
Mailing Address - Phone:810-989-3234
Mailing Address - Fax:810-985-6061
Practice Address - Street 1:1221 PINE GROVE AVE
Practice Address - Street 2:LABORATORY PORT HURON HOSPITAL
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3511
Practice Address - Country:US
Practice Address - Phone:810-898-3234
Practice Address - Fax:810-985-6061
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301059987207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2869778Medicaid
MI2869778Medicaid
MIOG462518Medicare ID - Type Unspecified