Healthcare Provider Details

I. General information

NPI: 1679524094
Provider Name (Legal Business Name): ANTHONY ANDERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1479A U.S. HIGHWAY 61
FESTUS MO
63028-4123
US

IV. Provider business mailing address

1479A U.S. HIGHWAY 61
FESTUS MO
63028-4123
US

V. Phone/Fax

Practice location:
  • Phone: 636-931-5533
  • Fax: 636-931-5502
Mailing address:
  • Phone: 636-931-5533
  • Fax: 636-931-5502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMDR7H67
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036119093
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number036119093
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number036119093
License Number StateIL
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036119093
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: