Basic Information
| Provider Information | |||||||||
| NPI: | 1356351688 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 TERRY AVE FL 8 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981012735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062876300 | ||||||||
| FaxNumber: | 2063411250 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 TERRY AVE FL 8 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981012735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062876300 | ||||||||
| FaxNumber: | 2063411250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 03/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | L5224 | TX | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | MD60481560 | WA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 2044576 | 05 | WA | MEDICAID | 161225101 | 05 | TX | MEDICAID | 8F8791 | 01 | TX | BCBS | OTHER | 133275100 | 01 | TX | FIRST CARE | OTHER |