MEDICARE: JIMMY G. ANDERSON, D.C.

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	111N00000X	Chiropractor	3048	KY
2	111N00000X	Chiropractor	1217	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	20135AN	OTHER	MN	BCBS
2	ON362AN	OTHER	MN	BCBS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043217433
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JIMMY G. ANDERSON, D.C.

Provider Business Mailing Address
First Line	:	BOX 831
Second Line	:	3394 LAKE ELMO AVENUE NORTH
City	:	LAKE ELMO
State	:	MN
Zip	:	55042-0831
Country	:	US
Telephone Number	:	651-777-9757
Fax Number	:	651-777-9757

Provider Business Practice Location Address
First Line	:	3394 LAKE ELMO AVENUE
Second Line	:
City	:	LAKE ELMO
State	:	MN
Zip	:	55042-0831
Country	:	US
Telephone Number	:	651-777-9757
Fax Number	:	651-777-9757

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	MR. JIMMY G ANDERSON
Credential	:	D.C.
Telephone Number	:	651-777-9757

Provider Enumeration Date	:	06/30/2005
Last Update Date	:	02/06/2013

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