Basic Information
| Provider Information | |||||||||
| NPI: | 1669452397 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 1ST ST SW | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559050001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5072842511 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 1ST ST SW | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559050001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5072842511 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2006 | ||||||||
| LastUpdateDate: | 04/18/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35561 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080037177 | 01 | MN | RAILROAD MEDICARE | OTHER | P01147460 | 01 | MN | RAILROAD MEDICARE | OTHER | 763793400 | 05 | MN | MEDICAID |