Nicholas L Anderson
Individual provider Active NPI Pediatrics Physician · Neenah, WI
NPI 1366976409 · NPPES record last updated Jul 31, 2020
Key facts
- NPI
- 1366976409
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Pediatrics Physician 208000000X
- License
- 73724-20 (WI)
- Practice address
- 130 2ND St
Neenah, WI 54956-2883 - Phone
- (920) 969-7906
- Fax
- (920) 969-7979
- NPI assigned
- Apr 15, 2017
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in WI
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20201205000124 | WI | Practitioner - Pediatric Medicine |
4486065968 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 73724-20 | WI | MD | Pediatrics Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Thedacare, Incorporated | Current |
Accepting new patients |
Locations
4480 W Spencer St
Appleton, WI 54914
Phone (920) 738-4800
1818 N Meade St
Appleton, WI 54911
Phone (920) 731-4101
3 Neenah Ctr
Neenah, WI 54956
Phone (920) 454-4229
130 2nd St
Neenah, WI 54956
Phone (920) 729-2063
600 N Westhaven Dr
Oshkosh, WI 54904
Phone (920) 237-5000
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatrics Physician | 208000000X | 73724-20 | WI | Yes |
Addresses
Primary practice location
130 2ND St
Neenah, WI 54956-2883
Mailing address
130 2ND St
Neenah, WI 54956-2883
Phone (920) 969-7906
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1366976409 | Medicaid | WI |
Other providers in Neenah, WI
- Gloria Allhiser
- Michael Clifford Altekruse
- Alternative Health Initiative LLC
- Alexis Anderson
- Lisa Anderson
- Robert F. Anderson
- Fnu Anusha
- Roshani Aryal
- Corbin Charles Asbury
- Ascension Medical Group-Fox Valley Wisconsin, Inc
All providers in Neenah, WI · Pediatrics Physician in Wisconsin
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 31, 2020. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.