Provider Demographics
NPI:1033140561
Name:ANDERSON, GREGORY S (DO)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:S
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 497
Mailing Address - Street 2:
Mailing Address - City:REDLAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56671-0497
Mailing Address - Country:US
Mailing Address - Phone:218-679-3912
Mailing Address - Fax:218-679-0181
Practice Address - Street 1:HWY 1 HOSPITAL DRIVE
Practice Address - Street 2:BOX 497
Practice Address - City:RED LAKE
Practice Address - State:MN
Practice Address - Zip Code:56671-0497
Practice Address - Country:US
Practice Address - Phone:218-679-3912
Practice Address - Fax:218-679-0181
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN32831208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN34G00ANOtherBC/BS OF MN
MN476753500Medicaid
MN8HZ116Medicare PIN
MN476753500Medicaid
MN34G00ANOtherBC/BS OF MN
MNHSZ009Medicare PIN
MN240206Medicare Oscar/Certification