Provider Demographics
NPI:1558604231
Name:ANTHONY J ANDERSON MD & ASSOC LLC
Entity Type:Organization
Organization Name:ANTHONY J ANDERSON MD & ASSOC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:JUDD
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-878-9432
Mailing Address - Street 1:1404 POMERELLE AVE STE B
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-2013
Mailing Address - Country:US
Mailing Address - Phone:208-878-9432
Mailing Address - Fax:208-878-4576
Practice Address - Street 1:1404 POMERELLE AVE STE B
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2013
Practice Address - Country:US
Practice Address - Phone:208-878-9432
Practice Address - Fax:208-878-4576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-01
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-11018207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1508021726Medicaid
ID1508021726Medicare NSC