Provider Demographics
NPI:1558682401
Name:KERRY LYNN ANDERS MD AMC
Entity Type:Organization
Organization Name:KERRY LYNN ANDERS MD AMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:ANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-322-7744
Mailing Address - Street 1:3400 MEDICAL PARK DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203
Mailing Address - Country:US
Mailing Address - Phone:318-322-7744
Mailing Address - Fax:318-387-3336
Practice Address - Street 1:3400 MEDICAL PARK DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203
Practice Address - Country:US
Practice Address - Phone:318-322-7744
Practice Address - Fax:318-387-3336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-15
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD016804207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1354759Medicaid
LA1354759Medicaid