Provider Demographics
NPI:1710043583
Name:ANDERSON MEDICAL GROUP
Entity Type:Organization
Organization Name:ANDERSON MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:D
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-424-4841
Mailing Address - Street 1:600 18TH ST
Mailing Address - Street 2:SUITE 112
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-3231
Mailing Address - Country:US
Mailing Address - Phone:304-424-4841
Mailing Address - Fax:304-424-4858
Practice Address - Street 1:400 MATTHEW ST
Practice Address - Street 2:STE 101
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-1656
Practice Address - Country:US
Practice Address - Phone:304-424-4841
Practice Address - Fax:304-424-4858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV14185174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9331962Medicare PIN
WV9331961Medicare PIN