1760416390 NPI number — DR. RAYMOND GERALD ANDERSON PH.D.

Table of content: DR. RAYMOND GERALD ANDERSON PH.D. (NPI 1760416390)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760416390 NPI number — DR. RAYMOND GERALD ANDERSON PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
RAYMOND
Provider Middle Name:
GERALD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
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:
1760416390
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10864 CAROLYN CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLAND PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60467-4556
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-634-7727
Provider Business Mailing Address Fax Number:
928-669-3311

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
PARKER INDIAN HEALTH CENTER
Provider Second Line Business Practice Location Address:
12033 AGENCY RD
Provider Business Practice Location Address City Name:
PARKER
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85344
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-669-3373
Provider Business Practice Location Address Fax Number:
928-669-3311
Provider Enumeration Date:
07/10/2006

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: 103TC0700X , 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: 638067 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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