Provider Demographics
NPI:1811059264
Name:ANDERSON, BRYAN J (MD)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:J
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:PO BOX 8007
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-0507
Mailing Address - Country:US
Mailing Address - Phone:208-882-4511
Mailing Address - Fax:208-883-6580
Practice Address - Street 1:2400 W A ST STE G
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-4902
Practice Address - Country:US
Practice Address - Phone:208-883-1177
Practice Address - Fax:208-892-0170
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7735208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805476700Medicaid
IDG96450Medicare UPIN
ID11421911Medicare UPIN