=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154328193
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES GLEN SANDERSON DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2005
-----------------------------------------------------
Last Update Date | 01/04/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3 WEBSTER AVE
-----------------------------------------------------
City | JERSEY CITY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07307-1824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-216-1505
-----------------------------------------------------
Fax | 201-216-8803
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6 HUDSON CT APARTMENT #3-B
-----------------------------------------------------
City | BAYONNE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07002-2135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-216-1505
-----------------------------------------------------
Fax | 201-216-8803
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 25MB07524000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------