Basic Information
| Provider Information | |||||||||
| NPI: | 1588862114 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | COREY | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 BELLEFONTAINE AVE | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458042800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199984575 | ||||||||
| FaxNumber: | 4199984586 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 BELLEFONTAINE AVE | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458042800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199984575 | ||||||||
| FaxNumber: | 4199984586 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2007 | ||||||||
| LastUpdateDate: | 01/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | R8025 | IA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 0101260667 | VA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 35.098567 | OH | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | ME109122 | FL | N | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 35.098567 | 01 | OH | OH STATE LICENSE | OTHER | ME109122 | 01 | FL | FL STATE LICENSE | OTHER | 0066908 | 05 | OH | MEDICAID |