Provider Demographics
NPI:1407843683
Name:ANDERSON, ANGELA K (MD)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:K
Last Name:ANDERSON
Suffix:
Gender:F
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 6020
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57709-6020
Mailing Address - Country:US
Mailing Address - Phone:605-342-3280
Mailing Address - Fax:
Practice Address - Street 1:2820 MOUNT RUSHMORE RD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-5462
Practice Address - Country:US
Practice Address - Phone:605-342-3280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036094384207V00000X
WI61886207V00000X
SD9035207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00009296OtherMEDICARE RR
IL5236530001OtherMEDICARE DME ID
SDS110477Medicare PIN
ILP00009296OtherMEDICARE RR
ILG81860Medicare UPIN
IL384913OtherHEALTHLINK
IL5236530001OtherMEDICARE DME ID
ILIL0101OtherJOHN DEERE
ILL97948Medicare PIN