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: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 CLINT HILL BLVD
PADUCAH KY
42001-6768
US

IV. Provider business mailing address

200 CLINT HILL BLVD
PADUCAH KY
42001-6768
US

V. Phone/Fax

Practice location:
  • Phone: 270-442-9461
  • Fax: 270-441-0079
Mailing address:
  • Phone: 270-442-9461
  • Fax: 270-441-0079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number361168134
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberTP215
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberOP61396249
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: