Provider Demographics
NPI:1528048881
Name:ANDERSEN, JAMES R (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:R
Last Name:ANDERSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 678268
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-8268
Mailing Address - Country:US
Mailing Address - Phone:800-841-4236
Mailing Address - Fax:706-653-1162
Practice Address - Street 1:700 S PARK ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1849
Practice Address - Country:US
Practice Address - Phone:608-251-6100
Practice Address - Fax:608-826-2710
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI352052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32017900Medicaid
000954365Medicare ID - Type Unspecified
WI32017900Medicaid
F67711Medicare UPIN
000327060Medicare ID - Type Unspecified