Provider Demographics
NPI:1346409109
Name:ANDERSON, IAN P (MD)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:P
Last Name:ANDERSON
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:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-272-5395
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:825 BARRET AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204-1743
Practice Address - Country:US
Practice Address - Phone:502-540-7200
Practice Address - Fax:502-540-7210
Is Sole Proprietor?:No
Enumeration Date:2008-06-06
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KYTP861207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY126735OtherSIHO - NCMA
KY50033806OtherPASSPORT - NCMA
KY7100164430Medicaid
KY000000718931OtherANTHEM - NCMA
IN7100164430Medicaid
KY000057120ROtherHUMANA - NCMA
IN201033230OtherMEDICAID - NCMA
KY7100164430Medicaid