Provider Demographics
NPI:1851300503
Name:BRUCE J ANDERSEN MD PHD PA
Entity Type:Organization
Organization Name:BRUCE J ANDERSEN MD PHD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:J
Authorized Official - Last Name:ANDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD PHD
Authorized Official - Phone:208-367-3500
Mailing Address - Street 1:6140 CURTISIAN AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8880
Mailing Address - Country:US
Mailing Address - Phone:208-367-3500
Mailing Address - Fax:208-367-2968
Practice Address - Street 1:6140 CURTISIAN AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8880
Practice Address - Country:US
Practice Address - Phone:208-367-3500
Practice Address - Fax:208-367-2968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7767207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID72504OtherBLUE CROSS OF IDAHO
WA145403OtherWA DEPARTMENT OF LABOR
ID805457400Medicaid
ID134024OtherOMAP
185529500OtherUS DEPARTMENT OF LABOR
ID000010026334OtherREGENCE BLUE SHIELD
ID8J703OtherBLUE CROSS OF IDAHO GROUP
ID87732500Medicaid
F21975Medicare UPIN
ID87732500Medicaid
ID805457400Medicaid
ID8J703OtherBLUE CROSS OF IDAHO GROUP