Healthcare Provider Details

I. General information

NPI: 1992910699
Provider Name (Legal Business Name): ANDERS P. NELSON, MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 01/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 LAYTON ROAD
CLARKS SUMMIT PA
18411
US

IV. Provider business mailing address

PO BOX 399
CHINCHILLA PA
18410-0399
US

V. Phone/Fax

Practice location:
  • Phone: 570-586-8879
  • Fax:
Mailing address:
  • Phone: 570-586-8879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD043822E
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0011992910001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: DR. ANDERS P NELSON
Title or Position: OWNER
Credential: MD
Phone: 570-586-8879