Provider Demographics
NPI:1215014592
Name:ANDERSON, RICHARD O (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:O
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 W LAKE ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-4527
Mailing Address - Country:US
Mailing Address - Phone:612-925-6033
Mailing Address - Fax:612-925-8496
Practice Address - Street 1:3100 W LAKE ST
Practice Address - Street 2:SUITE 210
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55416-4527
Practice Address - Country:US
Practice Address - Phone:612-925-6033
Practice Address - Fax:612-925-8496
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN152792084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP15795OtherHEALTHPARTNERS
MN285583600Medicaid
MN321G7ANOtherBCBS
MN1552260OtherUBH
MN260002431Medicare ID - Type Unspecified
MN285583600Medicaid