Provider Demographics
NPI:1992910699
Name:ANDERS P. NELSON, MD, PC
Entity type:Organization
Organization Name:ANDERS P. NELSON, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDERS
Authorized Official - Middle Name:P
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-586-8879
Mailing Address - Street 1:PO BOX 399
Mailing Address - Street 2:
Mailing Address - City:CHINCHILLA
Mailing Address - State:PA
Mailing Address - Zip Code:18410-0399
Mailing Address - Country:US
Mailing Address - Phone:570-586-8879
Mailing Address - Fax:
Practice Address - Street 1:110 LAYTON ROAD
Practice Address - Street 2:
Practice Address - City:CLARKS SUMMIT
Practice Address - State:PA
Practice Address - Zip Code:18411
Practice Address - Country:US
Practice Address - Phone:570-586-8879
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD043822E208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011992910001Medicaid
PA0011992910001Medicaid