Provider Demographics
NPI:1093819153
Name:ANDERSON, JAMES KYLE (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:KYLE
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 1:909 FULTON ST SE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-4800
Mailing Address - Country:US
Mailing Address - Phone:612-672-7422
Mailing Address - Fax:
Practice Address - Street 1:909 FULTON ST SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-4800
Practice Address - Country:US
Practice Address - Phone:612-672-7422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47836208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0147121Medicaid
IA0599407Medicaid
1044923OtherPREFERRED ONE
2380609OtherAMERICA'S PPO (ARAZ)
B666OtherCHAMPUS
HP55786OtherHEALTHPARTNERS
MN19-00701OtherMEDICA CHOICE
MN210077100Medicaid
MN135228OtherUCARE
MN153841OtherFV CAREGIVER
MN19-00018OtherMEDICA PRIMARY
WI34708900Medicaid
MN210077100Medicaid
MN135228OtherUCARE