Provider Demographics
NPI:1902883135
Name:ANDERSON, SAMUEL R (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:R
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4895 OLENTANGY RIVER RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-1926
Mailing Address - Country:US
Mailing Address - Phone:614-457-7732
Mailing Address - Fax:614-457-4346
Practice Address - Street 1:4895 OLENTANGY RIVER RD
Practice Address - Street 2:SUITE 100
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-1926
Practice Address - Country:US
Practice Address - Phone:614-457-7732
Practice Address - Fax:614-457-4346
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-29
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-08-0575207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2327486Medicaid
OHH57608Medicare UPIN
OH2327486Medicaid