Provider Demographics
NPI:1770583049
Name:ANDERSON, KEITH G (MD)
Entity type:Individual
Prefix:
First Name:KEITH
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 1:1211 UNION AVE STE 330
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-6655
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7460 WOLF RIVER BOULEVARD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138
Practice Address - Country:US
Practice Address - Phone:901-763-0200
Practice Address - Fax:901-761-4002
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN16687207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00116765Medicaid
TNP00854010OtherRAILROAD MEDICARE
AR117803001Medicaid
TN1519975Medicaid
TN4270275OtherBCBS
TNA98706Medicare UPIN
AR117803001Medicaid
TN4270275OtherBCBS