Basic Information
| Provider Information | |||||||||
| NPI: | 1427017730 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | JAY | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | DDS, MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 143 W FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275162539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199668596 | ||||||||
| FaxNumber: | 9198435515 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 MANNING DR | ||||||||
| Address2: | |||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275990001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199668596 | ||||||||
| FaxNumber: | 9198435515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 08/09/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 14786 | SC | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 29695 | NC | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 14786 | SC | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 6911153 | 05 | NC | MEDICAID | TL5625 | 05 | SC | MEDICAID |