Basic Information
| Provider Information | |||||||||
| NPI: | 1841459187 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SULLIVAN | ||||||||
| OtherFirstName: | KATHERINE | ||||||||
| OtherMiddleName: | J | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 116 DEFENSE HWY | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214017027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108979841 | ||||||||
| FaxNumber: | 4108979852 | ||||||||
| Practice Location | |||||||||
| Address1: | 116 DEFENSE HWY | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214017027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108979841 | ||||||||
| FaxNumber: | 4108979852 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2008 | ||||||||
| LastUpdateDate: | 07/06/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | D72375 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | D72375 | 01 | MD | MARYLAND STATE LICENSE | OTHER |