1528331642 NPI number — ANDERSON ORAL AND MAXILLOFACIAL SURGERY, P.S.C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528331642 NPI number — ANDERSON ORAL AND MAXILLOFACIAL SURGERY, P.S.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANDERSON ORAL AND MAXILLOFACIAL SURGERY, P.S.C
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1528331642
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/21/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1675 S MAIN ST
Provider Second Line Business Mailing Address:
LAUREL MEDICAL CENTER, LOWER LEVEL
Provider Business Mailing Address City Name:
LONDON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40741-2050
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-878-6126
Provider Business Mailing Address Fax Number:
606-878-0840

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1675 S MAIN ST
Provider Second Line Business Practice Location Address:
LAUREL MEDICAL CENTER, LOWER LEVEL
Provider Business Practice Location Address City Name:
LONDON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40741-2050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-878-6126
Provider Business Practice Location Address Fax Number:
606-878-0840
Provider Enumeration Date:
02/21/2012

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
ANDREW
Authorized Official Title or Position:
ORAL AND MAXILLOFACIAL SURGEON
Authorized Official Telephone Number:
606-878-6126

Provider Taxonomy Codes

  • Taxonomy code: 261QS0112X , with the licence number:  6656 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 64066566 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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