Healthcare Provider Details

I. General information

NPI: 1295739688
Provider Name (Legal Business Name): SUSAN M ANDERSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 MEDICAL ARTS BLVD STE 102
ANDERSON IN
46011-3437
US

IV. Provider business mailing address

1210 MEDICAL ARTS BLVD STE 102
ANDERSON IN
46011-3437
US

V. Phone/Fax

Practice location:
  • Phone: 765-298-4111
  • Fax: 765-298-4994
Mailing address:
  • Phone: 765-298-4111
  • Fax: 765-298-4994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number01027721
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: