Provider Demographics
NPI:1922050772
Name:ANDERSON, MARK EDWARD (MD PHD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9910 FRANKLIN SQUARE DR STE 2110
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21236-4902
Mailing Address - Country:US
Mailing Address - Phone:410-933-6423
Mailing Address - Fax:
Practice Address - Street 1:600 N WOLFE ST BLDG RM9026
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0005
Practice Address - Country:US
Practice Address - Phone:410-955-6642
Practice Address - Fax:410-614-8510
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD78761207RC0000X
IA36520207RC0000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA08098OtherWELLMARK BCBS
IA0488478Medicaid
F15531Medicare UPIN
IA0488478Medicaid
IA08098OtherWELLMARK BCBS