Provider Demographics
NPI:1508896960
Name:ANDERSON, PATRICK R (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:R
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 1:1100 REID PKWY
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1157
Mailing Address - Country:US
Mailing Address - Phone:765-935-4088
Mailing Address - Fax:765-966-2596
Practice Address - Street 1:1471 CHESTER BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1945
Practice Address - Country:US
Practice Address - Phone:765-935-4088
Practice Address - Fax:765-966-2596
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036460A207R00000X
OH35.077693207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000373591OtherBLUESHIELD REIDHOSP-EKG
000000681393OtherANTHEM (RPA)
OH0686726Medicaid
IN100257060Medicaid
IN903830IOtherMEDICARE REID EKG
IN100257060OtherMEDICAID REID EKG
OH0686726Medicaid
IN000000373591OtherBLUESHIELD REIDHOSP-EKG
IN00000082700OtherANTHEM
IN110136876Medicare PIN
IN258840DMedicare PIN
IN902290JMedicare PIN