Healthcare Provider Details

I. General information

NPI: 1023111606
Provider Name (Legal Business Name): CHARLOTTE MARIE ANDERSEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHARLOTTE MARIE BALCER MD

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 4TH STREET S
FARGO ND
58107
US

IV. Provider business mailing address

PO BOX 143
BADGER SD
57214
US

V. Phone/Fax

Practice location:
  • Phone: 701-476-7200
  • Fax:
Mailing address:
  • Phone: 605-983-5087
  • Fax: 605-983-4796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number10156
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMDR3657
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: