Provider Demographics
NPI:1467545541
Name:ANDERSON, KENNETH W (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:W
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 190
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37088-0190
Mailing Address - Country:US
Mailing Address - Phone:615-444-4070
Mailing Address - Fax:615-444-4099
Practice Address - Street 1:501 PARK AVE
Practice Address - Street 2:SUITE C
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-1706
Practice Address - Country:US
Practice Address - Phone:615-444-4070
Practice Address - Fax:615-444-4099
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2017-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD012869207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN40326OtherBCBS
TN3010646Medicaid
TN40326OtherBCBS
TNA97490Medicare UPIN