Healthcare Provider Details

I. General information

NPI: 1124438783
Provider Name (Legal Business Name): JULIE JELAINE ANDERSON D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2014
Last Update Date: 03/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 N RANDALL RD
ELGIN IL
60123-2300
US

IV. Provider business mailing address

1425 N RANDALL RD
ELGIN IL
60123-2300
US

V. Phone/Fax

Practice location:
  • Phone: 224-783-8950
  • Fax:
Mailing address:
  • Phone: 224-783-5437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036.142328
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: