Provider Demographics
NPI:1568676898
Name:GREG ANDERSON DC PC
Entity Type:Organization
Organization Name:GREG ANDERSON DC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:317-375-1664
Mailing Address - Street 1:7111 SOUTHEASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46239-1207
Mailing Address - Country:US
Mailing Address - Phone:317-375-1664
Mailing Address - Fax:317-352-1292
Practice Address - Street 1:7111 SOUTHEASTERN AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46239-1207
Practice Address - Country:US
Practice Address - Phone:317-375-1664
Practice Address - Fax:317-352-1292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN800759111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100071490BMedicaid
IN000000313712OtherANTHEM
IN100071490BMedicaid