Healthcare Provider Details

I. General information

NPI: 1649393927
Provider Name (Legal Business Name): JAY C ANDERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 07/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

729 N CUSTER AVE
GRAND ISLAND NE
68803-4311
US

IV. Provider business mailing address

998102 NEBRASKA MEDICAL CTR
OMAHA NE
68198-8102
US

V. Phone/Fax

Practice location:
  • Phone: 308-382-9266
  • Fax: 308-382-5290
Mailing address:
  • Phone: 402-559-6195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number23403
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: