Provider Demographics
NPI:1750643060
Name:JOHN C. ANDERSON, M.D., P.C.
Entity Type:Organization
Organization Name:JOHN C. ANDERSON, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-489-1122
Mailing Address - Street 1:831 NW COUNCIL DR
Mailing Address - Street 2:SUITE 130
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-3721
Mailing Address - Country:US
Mailing Address - Phone:503-489-1122
Mailing Address - Fax:503-489-1123
Practice Address - Street 1:831 NW COUNCIL DR
Practice Address - Street 2:SUITE 130
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3721
Practice Address - Country:US
Practice Address - Phone:503-489-1122
Practice Address - Fax:503-489-1123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-12
Last Update Date:2013-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD26880207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORH78126Medicare UPIN