Provider Demographics
NPI:1154309110
Name:ANDERSSON, GUNNAR BJ (MD)
Entity Type:Individual
Prefix:
First Name:GUNNAR
Middle Name:BJ
Last Name:ANDERSSON
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 1:1 WESTBROOK CORPORATE CTR
Mailing Address - Street 2:SUITE #240
Mailing Address - City:WESTCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:60154-5701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1611 W HARRISON ST
Practice Address - Street 2:STE 400
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3841
Practice Address - Country:US
Practice Address - Phone:312-243-4244
Practice Address - Fax:312-243-2744
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036071119207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036071119Medicaid
IL207067OtherMEDICARE PTAN LOCALITY 16
IL207073OtherMEDICARE PTAN LOCALITY 15
4020836OtherAETNA
IL1633878OtherBCBS
DA4902OtherRAILROAD MEDICARE PTAN
P00094329OtherRAILROAD MEDICARE
IL1633878OtherBCBS
ILK01181Medicare PIN
ILC45675Medicare UPIN