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NPI Code Detail

MEDICARE: JACK D ANDERSON

MEDICARE: JACK D ANDERSON
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
1208000000XPediatrics Physician30586NC

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
211152OTHERNCBCBS
3MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1417976234
Entity Type Code : Individual
Provider Name (Legal Business Name) : JACK D ANDERSON
Provider Business Mailing Address
First Line : PO BOX 601067
Second Line :
City : CHARLOTTE
State : NC
Zip : 28260-1067
Country : US
Telephone Number : 704-667-4150
Fax Number : 704-752-7040
Provider Business Practice Location Address
First Line : 7030 PINEVILLE MATTHEWS RD
Second Line :
City : CHARLOTTE
State : NC
Zip : 28226-8298
Country : US
Telephone Number : 704-667-4150
Fax Number : 704-752-7040
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/19/2006
Last Update Date : 06/25/2013

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Directions to “ JACK D ANDERSON ” Practice Location

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