Provider Demographics
NPI:1457419160
Name:ANDERSON, MARY BETH (DO)
Entity type:Individual
Prefix:DR
First Name:MARY BETH
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18756 MILLAR RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-2095
Mailing Address - Country:US
Mailing Address - Phone:586-381-0177
Mailing Address - Fax:859-987-7661
Practice Address - Street 1:18756 MILLAR RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48036-2095
Practice Address - Country:US
Practice Address - Phone:586-381-0177
Practice Address - Fax:859-987-7661
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011355207ZD0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2155003214OtherBCBS
MI2155003214OtherBCBS
MIOEO6061007Medicare ID - Type Unspecified