Provider Demographics
NPI:1679524094
Name:ANDERSON, ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
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 1:1479A U.S. HIGHWAY 61
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-4123
Mailing Address - Country:US
Mailing Address - Phone:636-931-5533
Mailing Address - Fax:636-931-5502
Practice Address - Street 1:1479A U.S. HIGHWAY 61
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-4123
Practice Address - Country:US
Practice Address - Phone:636-931-5533
Practice Address - Fax:636-931-5502
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMDR7H67207L00000X
IL036119093207L00000X, 208VP0014X, 208VP0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200132704OtherCDS
MO205069909Medicaid
IL036119093Medicaid
IL036119093Medicaid
MO200132704OtherCDS
MO205069909Medicaid