Basic Information
| Provider Information | |||||||||
| NPI: | 1538112602 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | ANSEL | ||||||||
| MiddleName: | GLEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3490 | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370433490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9316475034 | ||||||||
| FaxNumber: | 9315526663 | ||||||||
| Practice Location | |||||||||
| Address1: | 4220 HARDING RD | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372052005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152222111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 04/14/2008 | ||||||||
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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 | 174400000X | MD40430 | TN | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | P00313053 | 01 | TN | RAILROAD MEDICARE | OTHER | 3335732 | 05 | TN | MEDICAID | 4118861 | 01 | TN | BCBS PROVIDER NUMBER | OTHER |