Provider Demographics
NPI:1124088455
Name:ANDERSON, KATHY ANN (MD)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:ANN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:ANN
Other - Last Name:HUSSONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2240 GATEWAY DR
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178
Mailing Address - Country:US
Mailing Address - Phone:815-756-8571
Mailing Address - Fax:815-756-1790
Practice Address - Street 1:2240 GATEWAY DR
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178
Practice Address - Country:US
Practice Address - Phone:815-756-8571
Practice Address - Fax:815-756-1790
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036071921207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036071921Medicaid
ILL71596OtherMEDICARE
E24734Medicare UPIN
IL036071921Medicaid