Basic Information
| Provider Information | |||||||||
| NPI: | 1669541868 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | SANDRA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 N BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | DES PLAINES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600162335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472983150 | ||||||||
| FaxNumber: | 8472985235 | ||||||||
| Practice Location | |||||||||
| Address1: | 4220 W 95TH ST STE 210 | ||||||||
| Address2: | |||||||||
| City: | OAK LAWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604532793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129494200 | ||||||||
| FaxNumber: | 7084231899 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 05/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 036-117093 | IL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 036-117093 | 01 | IL | STATE LICENSE | OTHER |