Basic Information
| Provider Information | |||||||||
| NPI: | 1346399391 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANDERSON AND ODUNSI, MD LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 MEMORIAL DR | ||||||||
| Address2: | SUITE 305 | ||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625263950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178768370 | ||||||||
| FaxNumber: | 2178768375 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 MEMORIAL DR | ||||||||
| Address2: | SUITE 305 | ||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625263950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178768370 | ||||||||
| FaxNumber: | 2178768375 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 08/07/2012 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
| AuthorizedOfficialMiddleName: | K. | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DOCTOR OB-GYN | ||||||||
| AuthorizedOfficialTelephone: | 2178768370 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 036069886 | IL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 363LW0102X | 209000428 | IL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 363L00000X | 209001529 | IL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207V00000X | 036094384 | IL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | DA0763 | 01 | IL | MEDICARE RAILROAD | OTHER | 05832021 | 01 | IL | BLUE CROSS BLUE SHIELD GR | OTHER |