Provider Demographics
NPI:1477733095
Name:ANDERSEN, ADAM (PT)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:ANDERSEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 207
Mailing Address - Street 2:
Mailing Address - City:WORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60482-0207
Mailing Address - Country:US
Mailing Address - Phone:708-403-1155
Mailing Address - Fax:708-403-1177
Practice Address - Street 1:100 E WALTON STREET
Practice Address - Street 2:SUITE 700
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-1448
Practice Address - Country:US
Practice Address - Phone:312-642-3963
Practice Address - Fax:312-642-3966
Is Sole Proprietor?:No
Enumeration Date:2007-11-12
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL07013087174400000X
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK49421Medicare PIN