Basic Information
| Provider Information | |||||||||
| NPI: | 1013058254 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | LUTHER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5465 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SYLVANIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435602155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198858800 | ||||||||
| FaxNumber: | 4198858600 | ||||||||
| Practice Location | |||||||||
| Address1: | 5465 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SYLVANIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435602155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198858800 | ||||||||
| FaxNumber: | 4198858600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 88744 | OH | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 4301085123 | 01 | MI | PHYSICIAN LICENSE | OTHER | 88744 | 01 | OH | DR OF MEDICINE | OTHER |