Basic Information
| Provider Information | |||||||||
| NPI: | 1689653750 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | RYAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1460 | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224021460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407862100 | ||||||||
| FaxNumber: | 5407860677 | ||||||||
| Practice Location | |||||||||
| Address1: | 12101 CAROL LN | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224076101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407867810 | ||||||||
| FaxNumber: | 5407863099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2006 | ||||||||
| LastUpdateDate: | 03/21/2012 | ||||||||
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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 | 207Q00000X | 0101040122 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0101040122 | 01 | VA | LICENSE | OTHER | 0897726 | 01 | VA | AETNA HMO | OTHER | 4091285 | 01 | VA | AETNA NON HMO | OTHER | 82934 | 01 | VA | MAMSI | OTHER | 000090765 | 01 | VA | AETNA CAP | OTHER | 005654432 | 05 | VA | MEDICAID | 175034 | 01 | VA | ANTHEM | OTHER | CA9037 | 01 | VA | MCR RAILROAD GROUP | OTHER | C02375 | 01 | VA | MEDICARE GROUP | OTHER |