Provider Demographics
NPI:1780708958
Name:ANDERSON, DEAN CHARLES (MA, PT, CERT MDT)
Entity type:Individual
Prefix:MR
First Name:DEAN
Middle Name:CHARLES
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MA, PT, CERT MDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 HURSTBOURNE LN
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62629-8677
Mailing Address - Country:US
Mailing Address - Phone:217-391-4662
Mailing Address - Fax:
Practice Address - Street 1:2951 MONTVALE DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704
Practice Address - Country:US
Practice Address - Phone:217-698-4055
Practice Address - Fax:217-698-4056
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.011395225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL364526905OtherTAX ID#
IL560898OtherHEALTHLINK PROVIDER ID#
IL8432060OtherBCBS PROVIDER ID #
ILL98241Medicare ID - Type UnspecifiedMEMBER #