Healthcare Provider Details

I. General information

NPI: 1518282110
Provider Name (Legal Business Name): BASIL CLARENCE ANDERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2010
Last Update Date: 11/16/2024
Certification Date: 11/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 MAIN ST N
KIMBERLY ID
83341
US

IV. Provider business mailing address

794 EASTLAND DR
TWIN FALLS ID
83301-6856
US

V. Phone/Fax

Practice location:
  • Phone: 208-735-3938
  • Fax: 208-735-3939
Mailing address:
  • Phone: 208-734-3312
  • Fax: 208-734-5036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA120404
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD154424
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberSTUDENT
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM-11966
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: