1790706430 NPI number — JOHN C. ANDERSON MD

Table of content: JOHN C. ANDERSON MD (NPI 1790706430)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790706430 NPI number — JOHN C. ANDERSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
JOHN
Provider Middle Name:
C.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790706430
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5006 UNIVERSITY DRIVE, #3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLLEGEDALE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37315-5001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-489-1122
Provider Business Mailing Address Fax Number:
503-489-1123

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10101 SE MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 3008
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97216-2455
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-489-1122
Provider Business Practice Location Address Fax Number:
503-489-1123
Provider Enumeration Date:
07/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  C143100 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: S0422 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: MD450150 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: MD26880 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XX0005X , with the licence number: MD26880 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: 10506 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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