Basic Information
| Provider Information | |||||||||
| NPI: | 1871753152 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | DIANE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 W 22ND ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | OAK BROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605231563 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5510 S EAST ST STE H | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462271939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179248425 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2008 | ||||||||
| LastUpdateDate: | 05/31/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 01065758A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | P0084590 | 01 | IN | RAIL ROAD MEDICARE | OTHER | 200911340 | 05 | IN | MEDICAID |