Provider Demographics
NPI:1538112602
Name:ANDERSON, ANSEL GLEN (MD)
Entity Type:Individual
Prefix:
First Name:ANSEL
Middle Name:GLEN
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 3490
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-3490
Mailing Address - Country:US
Mailing Address - Phone:931-647-5034
Mailing Address - Fax:931-552-6663
Practice Address - Street 1:4220 HARDING RD
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37205-2005
Practice Address - Country:US
Practice Address - Phone:615-222-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD40430174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP00313053OtherRAILROAD MEDICARE
TN3335732Medicaid
TN4118861OtherBCBS PROVIDER NUMBER
TN3335732Medicaid