Basic Information
| Provider Information | |||||||||
| NPI: | 1922050772 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | MD PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9910 FRANKLIN SQUARE DR STE 2110 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212364902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109336423 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 600 N WOLFE ST BLDG RM9026 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212870005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109556642 | ||||||||
| FaxNumber: | 4106148510 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 03/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | D78761 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 08098 | 01 | IA | WELLMARK BCBS | OTHER | 0488478 | 05 | IA | MEDICAID |