Provider Demographics
NPI:1942270251
Name:BRYAN J ANDERSON MD PC
Entity Type:Organization
Organization Name:BRYAN J ANDERSON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-377-2273
Mailing Address - Street 1:1072 N LIBERTY ST
Mailing Address - Street 2:#201
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8706
Mailing Address - Country:US
Mailing Address - Phone:208-377-2273
Mailing Address - Fax:208-367-3059
Practice Address - Street 1:1072 N LIBERTY ST
Practice Address - Street 2:#201
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8706
Practice Address - Country:US
Practice Address - Phone:208-377-2273
Practice Address - Fax:208-367-3059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-26
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7735208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805476700Medicaid
ID805476700Medicaid
ID1142191Medicare PIN