Basic Information
| Provider Information | |||||||||
| NPI: | 1578520359 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 91734 | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232911734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8043586100 | ||||||||
| FaxNumber: | 8043427619 | ||||||||
| Practice Location | |||||||||
| Address1: | 417 N 11TH ST | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232985002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8048282775 | ||||||||
| FaxNumber: | 8048280191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 06/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | MD043142L | PA | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 42128384946 | 05 | IA | MEDICAID | 0414607 | 05 | IA | MEDICAID | 201006530 | 05 | IN | MEDICAID | 38321 | 01 | IA | WELLMARK BCBS IA | OTHER | 101854586 | 05 | PA | MEDICAID | 7714360 | 05 | IA | MEDICAID | 000000694554 | 01 | IN | ANTHEM PROVIDER NUMBER | OTHER |