Basic Information
Provider Information | |||||||||
NPI: | 1518965391 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ANDERSON | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | LEROY | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 715 N KANSAS AVE | ||||||||
Address2: | SUITE 205 | ||||||||
City: | HASTINGS | ||||||||
State: | NE | ||||||||
PostalCode: | 689014453 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4024634521 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 715 N KANSAS AVE | ||||||||
Address2: | SUITE 205 | ||||||||
City: | HASTINGS | ||||||||
State: | NE | ||||||||
PostalCode: | 689014453 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4024634521 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/14/2005 | ||||||||
LastUpdateDate: | 08/12/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 15995 | NE | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 7564835 | 01 | NE | DEA NUMBER | OTHER | NA1676011 | 01 | NE | MEDICARE PTAN | OTHER | 3040 | 01 | NE | BCBS | OTHER | 10026063700 | 05 | NE |   | MEDICAID | 47067537200 | 05 | NE |   | MEDICAID |