Provider Demographics
NPI:1932497807
Name:JOHN M. ANDERSEN M.D.
Entity Type:Organization
Organization Name:JOHN M. ANDERSEN M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-718-0165
Mailing Address - Street 1:933 N CHARLOTTE ST
Mailing Address - Street 2:SUITE 3-A
Mailing Address - City:POTTSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19464-3974
Mailing Address - Country:US
Mailing Address - Phone:610-323-9052
Mailing Address - Fax:610-323-3085
Practice Address - Street 1:933 N CHARLOTTE ST
Practice Address - Street 2:SUITE 3-A
Practice Address - City:POTTSTOWN
Practice Address - State:PA
Practice Address - Zip Code:19464-3974
Practice Address - Country:US
Practice Address - Phone:610-323-9052
Practice Address - Fax:610-323-3085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-13
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD039149E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011067390001Medicaid