Basic Information
| Provider Information | |||||||||
| NPI: | 1134486301 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | ANSON | ||||||||
| MiddleName: | LAMAR | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | HIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 750 N COMMONS DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605047940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6303035380 | ||||||||
| FaxNumber: | 6303035385 | ||||||||
| Practice Location | |||||||||
| Address1: | 167 STATE ST | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 251301139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043691123 | ||||||||
| FaxNumber: | 3043699001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2012 | ||||||||
| LastUpdateDate: | 03/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | 886 | WV | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
No ID Information.