Provider Demographics
NPI:1952383176
Name:ANDERSON, KYLE (MD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:32270 TELEGRAPH RD STE 220
Mailing Address - Street 2:
Mailing Address - City:BINGHAM FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-2405
Mailing Address - Country:US
Mailing Address - Phone:248-480-9080
Mailing Address - Fax:
Practice Address - Street 1:32270 TELEGRAPH RD STE 220B
Practice Address - Street 2:
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-2456
Practice Address - Country:US
Practice Address - Phone:248-480-9080
Practice Address - Fax:248-480-9081
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301074015207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KA074015OtherCHAMPUS-CHAMPUS
MI0767220001OtherADMINISTAR FEDERAL
MI0F31114OtherBCBS
MI0F33583OtherBCBS DME
MI411776310Medicaid
700H262250OtherBLUE CROSS-BLUE CROSS
KA074015OtherCOMMERCIAL-COMMERCIAL NUMBER
KA074015OtherCHAMPUS-CHAMPUS
MI0767220001OtherADMINISTAR FEDERAL