Provider Demographics
NPI:1902822836
Name:ANDERSON, JEFFREY (MD, FAEP)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD, FAEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 REMIT DR NO 3309
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60675-3309
Mailing Address - Country:US
Mailing Address - Phone:866-916-5259
Mailing Address - Fax:231-922-4030
Practice Address - Street 1:1007 LINCOLNWAY
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-3201
Practice Address - Country:US
Practice Address - Phone:219-326-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037772A207P00000X
IL207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN193810AMedicare PIN
E18487Medicare UPIN