Provider Demographics
NPI:1710935242
Name:ANDERSON, EDWIN (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
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 1:630 E NORTH AVE
Mailing Address - Street 2:DEPT OF FAMILY MEDICINE
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60188-1560
Mailing Address - Country:US
Mailing Address - Phone:630-458-5300
Mailing Address - Fax:
Practice Address - Street 1:630 E NORTH AVE
Practice Address - Street 2:
Practice Address - City:CAROL STREAM
Practice Address - State:IL
Practice Address - Zip Code:60188
Practice Address - Country:US
Practice Address - Phone:630-458-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36076114207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036076114Medicaid
IL399670OtherMEDICARE PTAN
IL036076114Medicaid