Provider Demographics
NPI:1578554648
Name:ANDERSON, STEPHEN L (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 N EDDY ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2808
Mailing Address - Country:US
Mailing Address - Phone:574-232-3327
Mailing Address - Fax:574-232-3369
Practice Address - Street 1:211 N EDDY ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2808
Practice Address - Country:US
Practice Address - Phone:574-232-3327
Practice Address - Fax:574-232-3369
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2010-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01026447A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100220690Medicaid
IN100220690Medicaid
IN146470RRMedicare ID - Type Unspecified