Provider Demographics
NPI:1770551335
Name:ANDERSON, EMILY J (MD)
Entity type:Individual
Prefix:DR
First Name:EMILY
Middle Name:J
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-3709
Mailing Address - Country:US
Mailing Address - Phone:715-392-1955
Mailing Address - Fax:715-392-1935
Practice Address - Street 1:2222 E 5TH ST
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-3709
Practice Address - Country:US
Practice Address - Phone:715-392-1955
Practice Address - Fax:715-392-1935
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50745207Q00000X
MN47604207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN01-21784OtherMEDICA
MN94G62ANOtherBCBSMN
MN080023383OtherMEDICARE PTAN
MN365458300Medicaid
MNI39257Medicare UPIN