Provider Demographics
NPI:1104863257
Name:ANDERSON, MICHAEL JAY (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAY
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2911 TOWER AVE
Mailing Address - Street 2:STE 4
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-5322
Mailing Address - Country:US
Mailing Address - Phone:715-392-4883
Mailing Address - Fax:715-392-4873
Practice Address - Street 1:2911 TOWER AVE
Practice Address - Street 2:STE 4
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-5322
Practice Address - Country:US
Practice Address - Phone:715-392-4883
Practice Address - Fax:715-392-4873
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2904111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38872400Medicaid
WI38872400Medicaid