Basic Information
| Provider Information | |||||||||
| NPI: | 1346409109 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | IAN | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 776351 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022725395 | ||||||||
| FaxNumber: | 5022725339 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 BARRET AVE | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402041743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025407200 | ||||||||
| FaxNumber: | 5025407210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2008 | ||||||||
| LastUpdateDate: | 09/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | TP861 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 126735 | 01 | KY | SIHO - NCMA | OTHER | 50033806 | 01 | KY | PASSPORT - NCMA | OTHER | 7100164430 | 05 | KY | MEDICAID | 000000718931 | 01 | KY | ANTHEM - NCMA | OTHER | 7100164430 | 05 | IN | MEDICAID | 000057120R | 01 | KY | HUMANA - NCMA | OTHER | 201033230 | 01 | IN | MEDICAID - NCMA | OTHER |