Provider Demographics
NPI:1972511418
Name:ANDERSON, MARY ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ANN
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 1:1001 MAIN ST W
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806-1307
Mailing Address - Country:US
Mailing Address - Phone:715-682-5601
Mailing Address - Fax:715-682-6878
Practice Address - Street 1:1001 MAIN ST W
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-1307
Practice Address - Country:US
Practice Address - Phone:715-682-5601
Practice Address - Fax:715-682-6878
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI28204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI28204OtherSTATE LICENSE
WI30806100Medicaid
WI30806100Medicaid
WIB84662Medicare UPIN
WI28204OtherSTATE LICENSE