Provider Demographics
NPI:1205995255
Name:ANDERSON, RURIC (ANDY) CLESBY (MD)
Entity type:Individual
Prefix:
First Name:RURIC (ANDY)
Middle Name:CLESBY
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 1:1020 N 12TH ST STE 5120
Mailing Address - Street 2:AURORA HEALTH CARE
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53233-1308
Mailing Address - Country:US
Mailing Address - Phone:414-219-7887
Mailing Address - Fax:414-219-7044
Practice Address - Street 1:1020 N 12TH ST
Practice Address - Street 2:INTERNAL MEDICINE CLINIC AURORA HEALTH CARE
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-1308
Practice Address - Country:US
Practice Address - Phone:414-219-7887
Practice Address - Fax:414-219-7044
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-093107207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00337332OtherRAILROAD MEDICARE
IL036093106Medicaid
IL036093106Medicaid
ILK14308Medicare PIN
ILP00337332OtherRAILROAD MEDICARE