Provider Demographics
NPI:1265637623
Name:ANDERSEN, MATTHEW ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:ROBERT
Last Name:ANDERSEN
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 1:120 W 22ND ST STE 200
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1563
Mailing Address - Country:US
Mailing Address - Phone:630-573-5000
Mailing Address - Fax:
Practice Address - Street 1:6948 W WINDSOR AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3335
Practice Address - Country:US
Practice Address - Phone:708-749-4617
Practice Address - Fax:708-749-0094
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036114336207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036 114336Medicaid
ILOTH 000Medicare UPIN
ILR03545Medicare PIN