Provider Demographics
NPI:1801854021
Name:ANDERSON, KIRK R (MD)
Entity Type:Individual
Prefix:
First Name:KIRK
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 1:1055 N 500 W
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-429-8000
Mailing Address - Fax:801-429-8150
Practice Address - Street 1:306 RIVER BEND LN
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-5625
Practice Address - Country:US
Practice Address - Phone:801-226-8880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1621571205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT0358OtherDMBA
UT04-00306OtherUNITED HEALTHCARE
UT870281028AN1OtherEMIA
UT110037852OtherPALMETTO GBA
UT14053OtherPEHP
UT870281028000Medicaid
UT107006625101OtherIHC HEALTHPLANS
UTQM0000000034OtherALTIUS
UT0358OtherDMBA
UTD07323Medicare UPIN
UT000001029Medicare ID - Type UnspecifiedMEDICARE