MEDICARE: DR. NILS ANDERSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician	036-108038	IL

General Provider Information

NPI Number	:	1033109368
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NILS ANDERSON M.D.

Provider Business Mailing Address
First Line	:	DEPT OF SPECIALTY MEDICINE, NAVAL HEALTH CLINIC
Second Line	:	3001A SIXTH ST, BLDG 200H
City	:	GREAT LAKES
State	:	IL
Zip	:	60088
Country	:	US
Telephone Number	:	847-688-3444
Fax Number	:	847-688-4487

Provider Business Practice Location Address
First Line	:	3001A 6TH ST
Second Line	:	DEPT OF SPECIALTY MEDICINE, NAVAL HEALTH CLINIC
City	:	GREAT LAKES
State	:	IL
Zip	:	60088-2811
Country	:	US
Telephone Number	:	847-688-3444
Fax Number	:	847-688-4487

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/27/2005
Last Update Date	:	07/08/2007

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