Provider Demographics
NPI:1447200936
Name:ANDERSON ENT, PA
Entity Type:Organization
Organization Name:ANDERSON ENT, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:DOLE
Authorized Official - Middle Name:P
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-226-2822
Mailing Address - Street 1:PO BOX 139
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29622-0139
Mailing Address - Country:US
Mailing Address - Phone:864-226-2822
Mailing Address - Fax:864-226-2882
Practice Address - Street 1:1206 CORNELIA RD
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-3349
Practice Address - Country:US
Practice Address - Phone:864-226-2822
Practice Address - Fax:864-226-2882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3157Medicaid
7018Medicare ID - Type Unspecified