Provider Demographics
NPI:1346234192
Name:ANDERSON, MARY (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 STILES RD STE 102
Mailing Address - Street 2:ATT: CHRISTINE VALLANTE
Mailing Address - City:SALEM
Mailing Address - State:NH
Mailing Address - Zip Code:03079-2853
Mailing Address - Country:US
Mailing Address - Phone:603-893-4352
Mailing Address - Fax:603-894-4522
Practice Address - Street 1:23 STILES RD STE 102
Practice Address - Street 2:ATT: CHRISTINE VALLANTE
Practice Address - City:SALEM
Practice Address - State:NH
Practice Address - Zip Code:03079-2853
Practice Address - Country:US
Practice Address - Phone:603-893-4352
Practice Address - Fax:603-894-4522
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA543602085R0202X
NH108412085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30200654Medicaid
MA3024211Medicaid
B74876Medicare UPIN
MAFX7729Medicare PIN
MA3024211Medicaid
NHRE5871Medicare PIN