Provider Demographics
NPI:1083726269
Name:ANDERSON, KEITH V (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:V
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 1:1900 COOKS HILL RD
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-9073
Mailing Address - Country:US
Mailing Address - Phone:360-736-2889
Mailing Address - Fax:360-736-3136
Practice Address - Street 1:1900 COOKS HILL RD
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-9073
Practice Address - Country:US
Practice Address - Phone:360-736-2889
Practice Address - Fax:360-736-3136
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00027725207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8118648Medicaid
WA000985304Medicare ID - Type Unspecified
WA8118648Medicaid
WA0351890001Medicare NSC