Provider Demographics
NPI:1972521300
Name:ANDERSON, GARY ERNEST (DC)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:ERNEST
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3307 MILLER
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:MO
Mailing Address - Zip Code:64424
Mailing Address - Country:US
Mailing Address - Phone:660-425-6311
Mailing Address - Fax:660-425-6377
Practice Address - Street 1:3307 MILLER
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:MO
Practice Address - Zip Code:64424
Practice Address - Country:US
Practice Address - Phone:660-425-6311
Practice Address - Fax:660-425-6377
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO003293111N00000X
PA003105L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
00002684Medicare ID - Type Unspecified