Provider Demographics
NPI:1376548925
Name:ANDERSON, PATRICK ST GEORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:ST GEORGE
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 1:120 IRVINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079-1904
Mailing Address - Country:US
Mailing Address - Phone:973-762-7270
Mailing Address - Fax:973-762-1980
Practice Address - Street 1:120 IRVINGTON AVE
Practice Address - Street 2:
Practice Address - City:SOUTH ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07079-1904
Practice Address - Country:US
Practice Address - Phone:973-762-7270
Practice Address - Fax:973-762-1980
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-19
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07363800207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MA07363800OtherMEDICAL LICENSES NUMBER
NJ9003703Medicaid
NJ066100Medicare ID - Type Unspecified
NJF27684Medicare UPIN