1134124191 NPI number — BRIAN D ANDERSON DO

Table of content: BRIAN D ANDERSON DO (NPI 1134124191)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134124191 NPI number — BRIAN D ANDERSON DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
BRIAN
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1134124191
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/16/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
865 LINCOLN RD
Provider Second Line Business Mailing Address:
STE L10
Provider Business Mailing Address City Name:
BETTENDORF
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52722-4159
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
563-355-9191
Provider Business Mailing Address Fax Number:
563-355-3419

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2526 41ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOLINE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61265-5016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-792-6540
Provider Business Practice Location Address Fax Number:
309-764-9326
Provider Enumeration Date:
06/16/2005

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: 207P00000X , with the licence number:  036-098957 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 036098957 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: IL01G3 . This is a "JOHN DEERE HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 479890019 . This is a "DMERC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 90767 . This is a "WELLMARK BC/BS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 036098957 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20212 . This is a "IOWA HEALTH SOLUTIONS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 048462 . This is a "HEALTH ALLIANCE" identifier . This identifiers is of the category "OTHER".




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