Provider Demographics
NPI:1700874294
Name:ANDERSON, JOHN G (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:G
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 1:1111 LEFFINGWELL AVE NE
Mailing Address - Street 2:STE 100
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525
Mailing Address - Country:US
Mailing Address - Phone:616-459-7101
Mailing Address - Fax:616-464-6170
Practice Address - Street 1:1111 LEFFINGWELL AVE NE
Practice Address - Street 2:STE 100
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525
Practice Address - Country:US
Practice Address - Phone:616-459-7101
Practice Address - Fax:616-464-6170
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070607207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
200030127OtherRAILROAD MEDICARE
442790001OtherADMINISTAR
MI3380119Medicaid
F89461Medicare UPIN
442790001OtherADMINISTAR
MI3380119Medicaid