Provider Demographics
NPI:1841365640
Name:ANDERSON, TAREK (MD)
Entity type:Individual
Prefix:
First Name:TAREK
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
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:PO BOX L2560
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43260-0001
Mailing Address - Country:US
Mailing Address - Phone:304-346-9400
Mailing Address - Fax:304-345-7320
Practice Address - Street 1:4605 MACCORKLE AVE SW
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1311
Practice Address - Country:US
Practice Address - Phone:304-346-9400
Practice Address - Fax:304-345-7320
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV18922208000000X, 2080N0001X
OH35065363208000000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001723812OtherMTN ST BCBS
WV0110693000Medicaid
3607462003OtherCIGNA HEALTHCARE
WV4505652OtherAETNA
KY64103021Medicaid
WVW45031OtherMOUNTAIN STATE BLUECROSS
OH0933682Medicaid