Healthcare Provider Details

I. General information

NPI: 1215191259
Provider Name (Legal Business Name): CHARLES KELLOGG ANDERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2008
Last Update Date: 08/05/2021
Certification Date: 08/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 COUNTRY CLUB PKWY
EUGENE OR
97401-6036
US

IV. Provider business mailing address

520 COUNTRY CLUB PKWY
EUGENE OR
97401-6036
US

V. Phone/Fax

Practice location:
  • Phone: 541-683-5001
  • Fax: 541-683-1422
Mailing address:
  • Phone: 541-683-5001
  • Fax: 541-683-1422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number125050891
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberMD161964
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: