Provider Demographics
NPI:1093033029
Name:ANDERSEN, DESIRE M (MD)
Entity Type:Individual
Prefix:
First Name:DESIRE
Middle Name:M
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DESIRE
Other - Middle Name:M
Other - Last Name:HURST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1234 NAPIER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-2112
Mailing Address - Country:US
Mailing Address - Phone:269-983-8500
Mailing Address - Fax:269-985-4535
Practice Address - Street 1:1234 NAPIER AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-2112
Practice Address - Country:US
Practice Address - Phone:269-983-8500
Practice Address - Fax:269-985-4535
Is Sole Proprietor?:No
Enumeration Date:2010-05-14
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301103974208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1093033029Medicaid
MIMI2051217Medicare PIN