Provider Demographics
NPI:1598741522
Name:ANDERSON, MARVIN
Entity Type:Individual
Prefix:
First Name:MARVIN
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 1:1028 HANNAH AVE
Mailing Address - Street 2:STE D
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-2963
Mailing Address - Country:US
Mailing Address - Phone:231-946-7360
Mailing Address - Fax:231-929-4775
Practice Address - Street 1:1028 HANNAH AVE
Practice Address - Street 2:STE D
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-2963
Practice Address - Country:US
Practice Address - Phone:231-946-7360
Practice Address - Fax:231-929-4775
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301030297207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4196720Medicaid
MIN13080002Medicare ID - Type Unspecified
MI4196720Medicaid