Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | 125.076207 | IL |
Y | 208600000X | Surgeon | 125.076207 | IL |
NPI | 1003436163 |
---|---|
Provider Name | Dr. Derrius J. Anderson |
First Address | Burr Ridge, IL 60527-6686 |
Second Address | Chicago, IL 60637-1443 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/04/2020 |
Last Update Date | 29/05/2020 |