Provider Demographics
NPI:1780673343
Name:ANDERSON, PHILIP BRADLEY (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:BRADLEY
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 1:2700 SE STRATUS AVE
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-6255
Mailing Address - Country:US
Mailing Address - Phone:615-849-5685
Mailing Address - Fax:
Practice Address - Street 1:2700 SE STRATUS AVE
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-6255
Practice Address - Country:US
Practice Address - Phone:615-849-5685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD181772084P0800X
ORMD230292084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3376285Medicaid
4225056OtherAETNA
OR500640579Medicaid
TN0129072OtherBLUE CROSS BLUE SHIELD
OR500640579Medicaid
TN3376285Medicaid
TNE73545Medicare UPIN
TN3054893Medicare PIN