1134106867 NPI number — CLINTON ANDERSON MD

Table of content: CLINTON ANDERSON MD (NPI 1134106867)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134106867 NPI number — CLINTON ANDERSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
CLINTON
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134106867
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3360
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97208-3360
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-366-2983
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12800 BOTHELL EVERETT HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EVERETT
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98208-6642
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-316-5150
Provider Business Practice Location Address Fax Number:
425-225-1006
Provider Enumeration Date:
12/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  41558 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: MD60037715 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 062M8AN . This is a "BLUE CROSS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 127521 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 390405933 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3526343 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8523219 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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