MEDICARE: DR. MARISSA LEA ANDERSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	262804	MA
2	208C00000X	Colon & Rectal Surgery Physician	83360	GA
3	390200000X	Student in an Organized Health Care Education/Training Program	BP10038035	TX
4	208C00000X	Colon & Rectal Surgery Physician	036.161754	IL

General Provider Information

NPI Number	:	1043539836
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARISSA LEA ANDERSON M.D.

Provider Business Mailing Address
First Line	:	1725 W HARRISON ST STE 1138
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-3845
Country	:	US
Telephone Number	:	312-942-7088
Fax Number	:

Provider Business Practice Location Address
First Line	:	1725 W HARRISON ST STE 1138
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-3845
Country	:	US
Telephone Number	:	312-942-7088
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/19/2010
Last Update Date	:	02/20/2023

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