Provider Demographics
NPI:1750366035
Name:ANDERSON, BERNADETTE R (MD)
Entity type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:R
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6096 E MAIN ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-4302
Mailing Address - Country:US
Mailing Address - Phone:614-577-0400
Mailing Address - Fax:614-577-0040
Practice Address - Street 1:6096 E MAIN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-4302
Practice Address - Country:US
Practice Address - Phone:614-577-0400
Practice Address - Fax:614-577-0040
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-09
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35.081226207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2457738Medicaid
OH4121893Medicare PIN
OHH97805Medicare UPIN