Healthcare Provider Details

I. General information

NPI: 1255420881
Provider Name (Legal Business Name): JOSHUA R ANDERSON DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 08/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2421 W MAIN ST STE A
CARBONDALE IL
62901
US

IV. Provider business mailing address

1702 CASTLEBERRY DR
MARION IL
62959-1572
US

V. Phone/Fax

Practice location:
  • Phone: 618-529-3201
  • Fax:
Mailing address:
  • Phone: 618-889-6295
  • Fax: 618-998-9993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160003800
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070018872
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: