MEDICARE: DR. JAMES S ANTHONY PHD, LP

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	103T00000X	Psychologist	LP1905	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	103077	OTHER	MN	U CARE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	21390CE-47774AN	OTHER	MN	BC/BS
4	61-13267	OTHER	MN	UBH

General Provider Information

NPI Number	:	1255431243
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMES S ANTHONY PHD, LP

Provider Business Mailing Address
First Line	:	4444 CENTERVILLE ROAD
Second Line	:	#235
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55127-3712
Country	:	US
Telephone Number	:	651-289-3111
Fax Number	:	651-289-3113

Provider Business Practice Location Address
First Line	:	4444 CENTERVILLE ROAD
Second Line	:	#235
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55127-3712
Country	:	US
Telephone Number	:	651-289-3111
Fax Number	:	651-426-6766

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

Provider Enumeration Date	:	09/22/2006
Last Update Date	:	07/21/2022

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