Healthcare Provider Details

I. General information

NPI: 1750643060
Provider Name (Legal Business Name): JOHN C. ANDERSON, M.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2012
Last Update Date: 02/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

831 NW COUNCIL DR SUITE 130
GRESHAM OR
97030-3721
US

IV. Provider business mailing address

831 NW COUNCIL DR SUITE 130
GRESHAM OR
97030-3721
US

V. Phone/Fax

Practice location:
  • Phone: 503-489-1122
  • Fax: 503-489-1123
Mailing address:
  • Phone: 503-489-1122
  • Fax: 503-489-1123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberMD26880
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD26880
License Number StateOR

VIII. Authorized Official

Name: JOHN ANDERSON
Title or Position: OWNER
Credential: M.D.
Phone: 503-489-1122