Provider Demographics
NPI:1083615041
Name:ANDERSON, KENT ERNEST (MD)
Entity Type:Individual
Prefix:MR
First Name:KENT
Middle Name:ERNEST
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 S 25TH ST
Mailing Address - Street 2:
Mailing Address - City:ESCANABA
Mailing Address - State:MI
Mailing Address - Zip Code:49829-1364
Mailing Address - Country:US
Mailing Address - Phone:906-786-4100
Mailing Address - Fax:906-786-3997
Practice Address - Street 1:128 S 25TH ST
Practice Address - Street 2:
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-1364
Practice Address - Country:US
Practice Address - Phone:906-786-4100
Practice Address - Fax:906-786-3997
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301043128207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1419958Medicaid
MI2002100152OtherBCBSM
B45948Medicare UPIN
MI1419958Medicaid