Provider Demographics
NPI:1417636747
Name:ANDERSON, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2244 JACKSON AVE APT 1516
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-9426
Mailing Address - Country:US
Mailing Address - Phone:702-487-2129
Mailing Address - Fax:
Practice Address - Street 1:250 UTICA AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11213-3931
Practice Address - Country:US
Practice Address - Phone:702-487-2129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-13
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator