Provider Demographics
NPI:1982454716
Name:ANDERSON, ETHAN JERRICK
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:JERRICK
Last Name:ANDERSON
Suffix:
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 1:1360 E 58TH ST APT G
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-5213
Mailing Address - Country:US
Mailing Address - Phone:507-995-8800
Mailing Address - Fax:
Practice Address - Street 1:1775 BALLARD RD
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1005
Practice Address - Country:US
Practice Address - Phone:847-318-9340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program