MEDICARE: DAVID C. ANDERHOLM, MD, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	55A48AN	OTHER	MN	BCBS

General Provider Information

NPI Number	:	1083725147
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAVID C. ANDERHOLM, MD, PA

Provider Business Mailing Address
First Line	:	7115 FORTHUN RD
Second Line	:	SUITE 105
City	:	BAXTER
State	:	MN
Zip	:	56425-8597
Country	:	US
Telephone Number	:	218-454-0090
Fax Number	:	218-454-0091

Provider Business Practice Location Address
First Line	:	7115 FORTHUN RD
Second Line	:	SUITE 105
City	:	BAXTER
State	:	MN
Zip	:	56425-8597
Country	:	US
Telephone Number	:	218-454-0090
Fax Number	:	218-454-0091

Authorized Official
Title or Position	:	DIRECTOR, PRESIDENT, SECRETARY, AND
Name	:	ELLIOT RICHELSON
Credential	:	M.D.
Telephone Number	:	904-605-4986

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	03/15/2023

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