Provider Demographics
NPI:1194819938
Name:ANDERSON, RONALD BERNHARD (MD)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:BERNHARD
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 77
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:PA
Mailing Address - Zip Code:19086-0077
Mailing Address - Country:US
Mailing Address - Phone:610-299-5979
Mailing Address - Fax:610-891-9955
Practice Address - Street 1:1088 W BALTIMORE PIKE STE 2105
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-5136
Practice Address - Country:US
Practice Address - Phone:610-565-5082
Practice Address - Fax:610-891-9955
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD038618L207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000946789-0003Medicaid
C33511Medicare UPIN
PA00946789Medicaid