Provider Demographics
NPI:1174652606
Name:ANDERSON, KEITH ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:ALAN
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-8680
Mailing Address - Fax:704-384-8684
Practice Address - Street 1:200 GREENWICH RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-2316
Practice Address - Country:US
Practice Address - Phone:704-384-8680
Practice Address - Fax:704-384-8684
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC133989207Q00000X
NC2007-01501207QA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5912419Medicaid
NC133989OtherLICENSE
SCN01507Medicaid
NCAC5385578R118OtherDEA
NC133989OtherLICENSE
NC2073475Medicare PIN