Jack Anderson, MD
Individual provider Active NPI Internal Medicine Physician · Appleton, WI
NPI 1992737522 · NPPES record last updated Nov 16, 2011
Key facts
- NPI
- 1992737522
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Internal Medicine Physician 207R00000X
- License
- 26238-020 (WI)
- Practice address
- 2500 E Capitol Dr
Appleton, WI 54911-8735 - Phone
- (920) 731-5811
- Fax
- (920) 738-6293
- NPI assigned
- Jul 6, 2006
- Sex
- Male
- Sole proprietor
- No
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 |
|---|---|---|---|---|
| I20051221000437 | WI | Practitioner - Internal Medicine | 2163444993 |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 26238-020 | WI | MD | Internal Medicine Physician |
Interoperability endpoints
- janderson10253@direct.thedacare.org
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Internal Medicine Physician | 207R00000X | 26238-020 | WI | Yes |
Addresses
Primary practice location
2500 E Capitol Dr
Appleton, WI 54911-8735
Mailing address
PO Box 8003
Appleton, WI 54912-8003
Phone (920) 996-3298
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 110048483 | Other | RR MEDICARE | |
| 711290042 | Other | WI | MEDICARE PTAN |
| 30608500 | Medicaid | WI | |
| 450030618 | Other | WI | MEDICARE PTAN |
Other providers in Appleton, WI
- Pamela J Andersen
- Chloe Anderson Kemp
- Ann Marie E. Anderson
- David M Anderson
- Heather Joi Anderson
- Jennifer Ashley Anderson
- Jill A Anderson
- Kristin G Anderson
- Michael Floyd Anderson
- William A Anderson
All providers in Appleton, WI · Internal Medicine 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 Nov 16, 2011. 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.