Provider Demographics
NPI:1659434108
Name:ANDERSON, KENNETH W III (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:W
Last Name:ANDERSON
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:14451 MORNINGSIDE RD
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-7413
Mailing Address - Country:US
Mailing Address - Phone:708-205-9008
Mailing Address - Fax:888-668-6550
Practice Address - Street 1:14451 MORNINGSIDE RD
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-7413
Practice Address - Country:US
Practice Address - Phone:708-205-9008
Practice Address - Fax:888-668-6550
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036-059551207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212433Medicare ID - Type UnspecifiedMEDICARE