Provider Demographics
NPI:1205800034
Name:ANDERSON, KENNETH C (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:C
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4003 KRESGE WAY
Mailing Address - Street 2:STE 312
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207
Mailing Address - Country:US
Mailing Address - Phone:502-899-7377
Mailing Address - Fax:502-899-1972
Practice Address - Street 1:4003 KRESGE WAY
Practice Address - Street 2:STE 312
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207
Practice Address - Country:US
Practice Address - Phone:502-899-7377
Practice Address - Fax:502-899-1972
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY25175207RS0012X, 207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY290010998OtherRR MEDICARE
KY1079146OtherPASSPORT
KY64251754Medicaid
E09335Medicare UPIN
KY1079146OtherPASSPORT