Provider Demographics
NPI:1619013265
Name:GREG ANDERSON MD LLC
Entity type:Organization
Organization Name:GREG ANDERSON MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-654-3400
Mailing Address - Street 1:1520 9TH ST
Mailing Address - Street 2:SUITE 230
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249-1677
Mailing Address - Country:US
Mailing Address - Phone:618-654-3400
Mailing Address - Fax:618-654-3442
Practice Address - Street 1:1520 9TH ST
Practice Address - Street 2:SUITE 230
Practice Address - City:HIGHLAND
Practice Address - State:IL
Practice Address - Zip Code:62249-1677
Practice Address - Country:US
Practice Address - Phone:618-654-3400
Practice Address - Fax:618-654-3442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILA45379Medicare UPIN