MEDICARE: DR. ANGELA K ANDERSON MD

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	207V00000X	Obstetrics & Gynecology Physician	036094384	IL
2	207V00000X	Obstetrics & Gynecology Physician	61886	WI
3	207V00000X	Obstetrics & Gynecology Physician	9035	SD

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00009296	OTHER	IL	MEDICARE RR
2	5236530001	OTHER	IL	MEDICARE DME ID

General Provider Information

NPI Number	:	1407843683
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANGELA K ANDERSON MD

Provider Business Mailing Address
First Line	:	PO BOX 6020
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57709-6020
Country	:	US
Telephone Number	:	605-342-3280
Fax Number	:

Provider Business Practice Location Address
First Line	:	2820 MOUNT RUSHMORE RD
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57701-5462
Country	:	US
Telephone Number	:	605-342-3280
Fax Number	:

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

Provider Enumeration Date	:	10/03/2005
Last Update Date	:	04/19/2016

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