Provider Demographics
NPI:1487638748
Name:ANDERSON, THOMAS M (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:M
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:PO BOX 1198
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:PA
Mailing Address - Zip Code:15501-0336
Mailing Address - Country:US
Mailing Address - Phone:814-444-1918
Mailing Address - Fax:814-444-9782
Practice Address - Street 1:10455 LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:PA
Practice Address - Zip Code:15537-7046
Practice Address - Country:US
Practice Address - Phone:814-444-1918
Practice Address - Fax:814-444-9782
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD072398L2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0676306000OtherPERSONAL CHOICE
PA332610OtherHIGHMARK BLUE SHIELD
PA217176OtherUPMC
MD407301100Medicaid
PA117880Medicaid
PA01183011505Medicaid
PA1514715Medicaid
PA1514715Medicaid
PA01183011505Medicaid
PA300117077Medicare PIN