Provider Demographics
NPI:1235699810
Name:ANDERSON, THOMAS GORMAN
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:GORMAN
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 E 23RD ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-4605
Mailing Address - Country:US
Mailing Address - Phone:646-518-0163
Mailing Address - Fax:
Practice Address - Street 1:212 E 23RD ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-4605
Practice Address - Country:US
Practice Address - Phone:646-518-0163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-21
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY315431261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program