Provider Demographics
NPI:1063420792
Name:ANDERSEN, BRUCE J (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:J
Last Name:ANDERSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:1072 N LIBERTY ST
Practice Address - Street 2:SUITE 303
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-2800
Practice Address - Country:US
Practice Address - Phone:208-367-4035
Practice Address - Fax:208-367-7111
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2023-02-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IDM7767207T00000X
IDM-7767207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
72504OtherBLUE CROSS OF IDAHO
OR134024OtherOMAP
ID805457400Medicaid
ID807732500Medicaid
185529500OtherUS DEPARTMENT OF LABOR
WA145403OtherWA DEPARTMENT OF LABOR
ID000010026334OtherREGENCE BLUE SHIELD
ID8J703OtherBLUE CROSS OF IDAHO GROUP
F21975Medicare UPIN
ID807732500Medicaid
1141883Medicare PIN
ID000010026334OtherREGENCE BLUE SHIELD