Provider Demographics
NPI:1629029723
Name:ANDERSON, BRIAN P (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:P
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:739 IRVING AVE
Mailing Address - Street 2:SUITE 450
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210
Mailing Address - Country:US
Mailing Address - Phone:315-470-7364
Mailing Address - Fax:315-470-5859
Practice Address - Street 1:739 IRVING AVE
Practice Address - Street 2:SUITE 450
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210
Practice Address - Country:US
Practice Address - Phone:315-470-7364
Practice Address - Fax:315-470-5859
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY1583701208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00958416Medicaid
020033106Medicare PIN
NY00958416Medicaid
C64734Medicare UPIN