Healthcare Provider Details

I. General information

NPI: 1518036136
Provider Name (Legal Business Name): SUSAN ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 08/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1204 W MAIN ST
CHARLOTTESVILLE VA
22903-2824
US

IV. Provider business mailing address

500 RAY C HUNT DR
CHARLOTTESVILLE VA
22903-2981
US

V. Phone/Fax

Practice location:
  • Phone: 434-924-0123
  • Fax: 434-243-3300
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101038242
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number0101038242
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: