Basic Information
Provider Information | |||||||||
NPI: | 1992995096 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ANDERSON | ||||||||
FirstName: | REBECCA | ||||||||
MiddleName: | B | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BENNETT | ||||||||
OtherFirstName: | REBECCA | ||||||||
OtherMiddleName: | L | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 601 GATEWAY BLVD N | ||||||||
Address2: |   | ||||||||
City: | CHESTERTON | ||||||||
State: | IN | ||||||||
PostalCode: | 463049658 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2199211444 | ||||||||
FaxNumber: | 2199215303 | ||||||||
Practice Location | |||||||||
Address1: | 601 GATEWAY BLVD N | ||||||||
Address2: |   | ||||||||
City: | CHESTERTON | ||||||||
State: | IN | ||||||||
PostalCode: | 463049658 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2199211444 | ||||||||
FaxNumber: | 2199215303 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/26/2007 | ||||||||
LastUpdateDate: | 10/13/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/13/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0105X | 01065426A | IN | Y |   | Allopathic & Osteopathic Physicians | Surgery | Surgery of the Hand | 207XS0106X | 01064086A | IN | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery |
ID Information
ID | Type | State | Issuer | Description | 300010454 | 05 | IN |   | MEDICAID |