Provider Demographics
NPI:1588629992
Name:ANDERSON, MARTHA MITCHELL (MD)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:MITCHELL
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 PENN AVENUE NORTH
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55411
Mailing Address - Country:US
Mailing Address - Phone:612-543-2500
Mailing Address - Fax:612-302-4870
Practice Address - Street 1:1313 PENN AVENUE NORTH
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55411
Practice Address - Country:US
Practice Address - Phone:612-543-2500
Practice Address - Fax:612-302-4870
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN231578207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN762895100Medicaid
080012308Medicare ID - Type Unspecified
F23566Medicare UPIN