Provider Demographics
NPI:1386838324
Name:ANDERSON, TREVOR RYAN (MD)
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:RYAN
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 6850
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57709-6850
Mailing Address - Country:US
Mailing Address - Phone:605-341-1414
Mailing Address - Fax:
Practice Address - Street 1:4141 5TH ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-6021
Practice Address - Country:US
Practice Address - Phone:605-341-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-04
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD85432081P2900X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1386838324OtherRR MEDICARE
SD1386838324Medicaid
SDP01112476OtherRR MEDICARE PTAN
SD0023-0001076OtherMEDICA
SD1386838324OtherTLC ADVANTAGE
SD1386838324OtherFIRST CHOICE OF THE MIDWEST
SD0300406OtherST OF WASH, DEPT OF LABOR
SD41194500700OtherNEBRASKA MEDICAID
SDS106597Medicare PIN
SD1386838324OtherFIRST CHOICE OF THE MIDWEST