Provider Demographics
NPI:1225455991
Name:ANDERSON SPORTS MEDICINE
Entity Type:Organization
Organization Name:ANDERSON SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-663-1900
Mailing Address - Street 1:32270 TELEGRAPH RD STE 220B
Mailing Address - Street 2:
Mailing Address - City:BINGHAM FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-2456
Mailing Address - Country:US
Mailing Address - Phone:248-480-9080
Mailing Address - Fax:248-480-9081
Practice Address - Street 1:32270 TELEGRAPH RD STE 220B
Practice Address - Street 2:
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-2456
Practice Address - Country:US
Practice Address - Phone:248-480-9080
Practice Address - Fax:248-480-9081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-19
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301074015207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M08420016Medicare PIN