Basic Information
| Provider Information | |||||||||
| NPI: | 1578510913 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | WALLACE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 662 | ||||||||
| Address2: | |||||||||
| City: | EDWARDSVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620250662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778335034 | ||||||||
| FaxNumber: | 4059486507 | ||||||||
| Practice Location | |||||||||
| Address1: | 4500 MEMORIAL DR | ||||||||
| Address2: | DEPT RADIOLOGY | ||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622265360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182579567 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 04/17/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 36082306 | IL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0360823063 | 05 | IL | MEDICAID | 1333997 | 01 | TN | BCBS OF TN | OTHER |