Provider Demographics
NPI:1346399391
Name:ANDERSON AND ODUNSI, MD LLC
Entity Type:Organization
Organization Name:ANDERSON AND ODUNSI, MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR OB-GYN
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:K
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-876-8370
Mailing Address - Street 1:2 MEMORIAL DR
Mailing Address - Street 2:SUITE 305
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-3950
Mailing Address - Country:US
Mailing Address - Phone:217-876-8370
Mailing Address - Fax:217-876-8375
Practice Address - Street 1:2 MEMORIAL DR
Practice Address - Street 2:SUITE 305
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-3950
Practice Address - Country:US
Practice Address - Phone:217-876-8370
Practice Address - Fax:217-876-8375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036094384207V00000X
IL036069886207V00000X
IL209001529363L00000X
IL209000428363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDA0763OtherMEDICARE RAILROAD
IL05832021OtherBLUE CROSS BLUE SHIELD GR
ILDA0763OtherMEDICARE RAILROAD