Healthcare Provider Details

I. General information

NPI: 1760820989
Provider Name (Legal Business Name): BRYAN G ANDERSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2013
Last Update Date: 12/10/2024
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 LINCOLN DRIVE
HERRIN IL
62948
US

IV. Provider business mailing address

510 LINCOLN DRIVE
HERRIN IL
62948
US

V. Phone/Fax

Practice location:
  • Phone: 618-997-6800
  • Fax: 618-997-1187
Mailing address:
  • Phone: 618-997-6800
  • Fax: 618-997-1187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberOP61396249
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number361168134
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: