MEDICARE: DR. JAMES GLEN SANDERSON DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	25MB07524000	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154328193
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMES GLEN SANDERSON DO

Provider Business Mailing Address
First Line	:	6 HUDSON CT
Second Line	:	APARTMENT #3-B
City	:	BAYONNE
State	:	NJ
Zip	:	07002-2135
Country	:	US
Telephone Number	:	201-216-1505
Fax Number	:	201-216-8803

Provider Business Practice Location Address
First Line	:	3 WEBSTER AVE
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07307-1824
Country	:	US
Telephone Number	:	201-216-1505
Fax Number	:	201-216-8803

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/06/2005
Last Update Date	:	01/04/2012

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