Provider Demographics
NPI:1346226958
Name:ANDERSON, JONATHAN HAL (MD, FACS)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:HAL
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:367 S. GULPH RD
Mailing Address - Street 2:ATTN: IPM CREDENTIALING
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406
Mailing Address - Country:US
Mailing Address - Phone:803-716-8712
Mailing Address - Fax:
Practice Address - Street 1:770 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-6307
Practice Address - Country:US
Practice Address - Phone:803-649-3903
Practice Address - Fax:803-642-6161
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC19933208800000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC199332Medicaid
SCG58186Medicare UPIN
SCCC5484OtherRR MEDICARE
SCG58186Medicare UPIN
SC199332Medicaid