MEDICARE: DR. JOHN ANDERSON D.O.

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	207R00000X	Internal Medicine Physician	036103841	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00015719	OTHER	IL	MEDICARE RAILROAD CARRIER

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	036-103841	OTHER	IL	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1962450049
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN ANDERSON D.O.

Provider Business Mailing Address
First Line	:	2507 N RICHMOND RD
Second Line	:
City	:	MCHENRY
State	:	IL
Zip	:	60051-5407
Country	:	US
Telephone Number	:	815-338-6600
Fax Number	:	815-344-8957

Provider Business Practice Location Address
First Line	:	2507 N RICHMOND RD
Second Line	:
City	:	MCHENRY
State	:	IL
Zip	:	60051
Country	:	US
Telephone Number	:	815-338-6600
Fax Number	:	815-344-8957

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

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	10/19/2018

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Directions to “ DR. JOHN ANDERSON D.O.” Practice Location

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