Provider Demographics
NPI:1104928464
Name:ANDERSON, ELLEN M (DPM)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:M
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 327
Mailing Address - Street 2:
Mailing Address - City:DOVER-FOXCROFT
Mailing Address - State:ME
Mailing Address - Zip Code:04426-0327
Mailing Address - Country:US
Mailing Address - Phone:207-564-2536
Mailing Address - Fax:207-564-8581
Practice Address - Street 1:839 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DOVER FOXCROFT
Practice Address - State:ME
Practice Address - Zip Code:04426-1334
Practice Address - Country:US
Practice Address - Phone:207-564-2536
Practice Address - Fax:207-564-8581
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPOD155213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME112960000Medicaid
T31431Medicare UPIN
ME015197Medicare PIN
ME1349170001Medicare NSC