1124406186 NPI number — MICHAEL A ANDERSON DO

Table of content: MICHAEL A ANDERSON DO (NPI 1124406186)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124406186 NPI number — MICHAEL A ANDERSON DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
MICHAEL
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124406186
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1489 PARTRIDGE CV
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POCATELLO
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83201-1988
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-648-4789
Provider Business Mailing Address Fax Number:
208-648-4790

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 POCATELLO CREEK RD STE E10
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201-2953
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-648-4789
Provider Business Practice Location Address Fax Number:
208-648-4790
Provider Enumeration Date:
05/11/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: O-1136 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1124406816 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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