Provider Demographics
NPI:1649547431
Name:ANDERE, ANTONIO JR
Entity type:Individual
Prefix:MR
First Name:ANTONIO
Middle Name:
Last Name:ANDERE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4618 W 115TH PL
Mailing Address - Street 2:
Mailing Address - City:ALSIP
Mailing Address - State:IL
Mailing Address - Zip Code:60803-2214
Mailing Address - Country:US
Mailing Address - Phone:708-529-8814
Mailing Address - Fax:
Practice Address - Street 1:4618 W 115TH PL
Practice Address - Street 2:
Practice Address - City:ALSIP
Practice Address - State:IL
Practice Address - Zip Code:60803-2214
Practice Address - Country:US
Practice Address - Phone:708-529-8814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-21
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.005548225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant