Provider Demographics
NPI:1235181629
Name:ANDERSON, KURT C (DO)
Entity Type:Individual
Prefix:
First Name:KURT
Middle Name:C
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:364 W WRIGHT AVE
Mailing Address - Street 2:
Mailing Address - City:SHEPHERD
Mailing Address - State:MI
Mailing Address - Zip Code:48883-2502
Mailing Address - Country:US
Mailing Address - Phone:989-828-6691
Mailing Address - Fax:989-828-6835
Practice Address - Street 1:364 W WRIGHT AVE
Practice Address - Street 2:
Practice Address - City:SHEPHERD
Practice Address - State:MI
Practice Address - Zip Code:48883-2502
Practice Address - Country:US
Practice Address - Phone:989-828-6691
Practice Address - Fax:989-828-6835
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI008087207PE0004X
MIKA008087207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3290700Medicaid
MIKA008087OtherBC/BS
MI3290700Medicaid