Basic Information
| Provider Information | |||||||||
| NPI: | 1275609489 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | SHANNON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1106 CHUCK DAWLEY BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MT PLEASANT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294644183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438491551 | ||||||||
| FaxNumber: | 8438496591 | ||||||||
| Practice Location | |||||||||
| Address1: | 1106 CHUCK DAWLEY BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MT PLEASANT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294644183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438491551 | ||||||||
| FaxNumber: | 8438496591 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 05/17/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 0090-01409 | NC | N | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | 25231 | SC | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0090-01409 | 01 | NC | NC MEDICAL BOARD | OTHER | T81578 | 05 | SC | MEDICAID |