Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204C00000X | Sports Medicine Doctor | 6950 | MT |
NPI | 1235286915 |
---|---|
Provider Name | Dr. Charles Bradley Anderson |
First Address | Helena, MT 59601-8098 |
Second Address | Helena, MT 59601-8098 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/01/2007 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
6950 | LICENSE NUMBER (01) | MT |