Healthcare Provider Details

I. General information

NPI: 1518055573
Provider Name (Legal Business Name): IAN CHURCHILL ANDERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 10/14/2021
Certification Date: 10/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3555 ROUND BARN CIR
SANTA ROSA CA
95403
US

IV. Provider business mailing address

3555 ROUND BARN CIR
SANTA ROSA CA
95403-1757
US

V. Phone/Fax

Practice location:
  • Phone: 707-528-1050
  • Fax:
Mailing address:
  • Phone: 707-528-1050
  • Fax: 707-525-3874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License NumberA49481
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberA49481
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberA49481
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: