Provider Demographics
NPI:1588685077
Name:ANDERSON, MICHAEL R (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
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 1:512 WILCOX ST
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-1254
Mailing Address - Country:US
Mailing Address - Phone:920-563-6667
Mailing Address - Fax:920-563-0145
Practice Address - Street 1:512 WILCOX ST
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-1254
Practice Address - Country:US
Practice Address - Phone:920-563-6667
Practice Address - Fax:920-563-0145
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45652-020207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34399400Medicaid
WI34399400Medicaid
WI001330345Medicare PIN
H88118Medicare UPIN