Provider Demographics
NPI:1477638625
Name:ANDERSON, SAMANTHA (PA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:LB# 7550, P.O. BOX 95000
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19195-7550
Mailing Address - Country:US
Mailing Address - Phone:844-362-1735
Mailing Address - Fax:973-290-7495
Practice Address - Street 1:1 DIAMOND HILL RD
Practice Address - Street 2:SUMMIT MEDICAL GROUP
Practice Address - City:BERKELEY HEIGHTS
Practice Address - State:NJ
Practice Address - Zip Code:07922-2104
Practice Address - Country:US
Practice Address - Phone:908-273-4300
Practice Address - Fax:908-219-3071
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00042800363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJS71759Medicare UPIN
NJ023416Medicare ID - Type Unspecified