Provider Demographics
NPI:1649393927
Name:ANDERSON, JAY C (MD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:C
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 1:998102 NEBRASKA MEDICAL CTR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68198-8102
Mailing Address - Country:US
Mailing Address - Phone:402-559-6195
Mailing Address - Fax:
Practice Address - Street 1:729 N CUSTER AVE
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4311
Practice Address - Country:US
Practice Address - Phone:308-382-9266
Practice Address - Fax:308-382-5290
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2016-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE23403207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47059252300Medicaid
NE97552001Medicare PIN