Provider Demographics
NPI:1053320671
Name:MELLGREN, ANDERS (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDERS
Middle Name:
Last Name:MELLGREN
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 1:840 S WOOD ST
Mailing Address - Street 2:SUITE 518 CSB - MC 957
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4325
Mailing Address - Country:US
Mailing Address - Phone:312-996-2061
Mailing Address - Fax:312-996-1214
Practice Address - Street 1:1801 W TAYLOR ST
Practice Address - Street 2:3F OCC
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4795
Practice Address - Country:US
Practice Address - Phone:312-355-4300
Practice Address - Fax:312-413-1206
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN45364208C00000X
IL036.133002208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036.133002Medicaid
MN764487600Medicaid
IL036.133002Medicaid
MN764487600Medicaid
IL1053320671Medicare PIN