Provider Demographics
NPI:1699703892
Name:ANDERSON, RICHARD (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 MAIN STREET
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61606-2037
Mailing Address - Country:US
Mailing Address - Phone:309-495-0200
Mailing Address - Fax:309-676-6545
Practice Address - Street 1:1001 MAIN STREET
Practice Address - Street 2:3RD FLOOR
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606-2037
Practice Address - Country:US
Practice Address - Phone:309-495-0200
Practice Address - Fax:309-676-6545
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036095602208600000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036095602-1Medicaid
IL020046522OtherRR MEDICARE
IL7215166OtherBLUE CROSS BLUE SHIELD
IL020046522OtherRR MEDICARE
ILH17441Medicare UPIN