Provider Demographics
NPI:1942202916
Name:ANDERSON, KEVIN (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
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 1:827 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-2015
Mailing Address - Country:US
Mailing Address - Phone:231-775-9741
Mailing Address - Fax:231-775-9333
Practice Address - Street 1:827 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-2015
Practice Address - Country:US
Practice Address - Phone:231-775-9741
Practice Address - Fax:231-775-9333
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKA075594207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4501451Medicaid
MI0808300492OtherBLUE CROSS/SHIELD INDIVIU
MI1942202916OtherRAILROAD MEDICARE
MI4217007Medicaid
MI0H36303OtherBLUE CROSS/SHIELD GROUP
MI4501451-10Medicaid
MI127350OtherPREFERRED CHOICE
MI0H36303006Medicare PIN
MI4217007Medicaid
MI4217007Medicaid
0N70960Medicare PIN