Provider Demographics
NPI:1114906609
Name:ANDERSON, CHRISTOPHER (MD)
Entity type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
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 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-5362
Mailing Address - Fax:505-923-5362
Practice Address - Street 1:120 SUMTER DR
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-9620
Practice Address - Country:US
Practice Address - Phone:704-660-6939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC37998207PE0004X
IL036142147207P00000X
NMMD2017-1020207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN37998Medicaid
NC7911160Medicaid
NC7911160Medicaid
IL214881Medicare Oscar/Certification
SCAA34479068Medicare PIN
NC2144726AMedicare ID - Type Unspecified
SCN37998Medicaid