Healthcare Provider Details

I. General information

NPI: 1033109368
Provider Name (Legal Business Name): NILS ANDERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001A 6TH ST DEPT OF SPECIALTY MEDICINE, NAVAL HEALTH CLINIC
GREAT LAKES IL
60088-2811
US

IV. Provider business mailing address

DEPT OF SPECIALTY MEDICINE, NAVAL HEALTH CLINIC 3001A SIXTH ST, BLDG 200H
GREAT LAKES IL
60088
US

V. Phone/Fax

Practice location:
  • Phone: 847-688-3444
  • Fax: 847-688-4487
Mailing address:
  • Phone: 847-688-3444
  • Fax: 847-688-4487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number036-108038
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: