Healthcare Provider Details

I. General information

NPI: 1841365640
Provider Name (Legal Business Name): TAREK ANDERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 05/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4605 MACCORKLE AVE SW
SOUTH CHARLESTON WV
25309-1311
US

IV. Provider business mailing address

PO BOX L2560
COLUMBUS OH
43260-0001
US

V. Phone/Fax

Practice location:
  • Phone: 304-346-9400
  • Fax: 304-345-7320
Mailing address:
  • Phone: 304-346-9400
  • Fax: 304-345-7320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number18922
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35065363
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number18922
License Number StateWV
# 4
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number35065363
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: