Basic Information
| Provider Information | |||||||||
| NPI: | 1528075793 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | ALBERT | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 255 WEST MICHIGAN AVENUE | ||||||||
| Address2: | PO BOX 1123 | ||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492011123 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 6605 ABERCORN ST STE 108 | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314055896 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123557214 | ||||||||
| FaxNumber: | 5177877365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 02/08/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | ME92106 | FL | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 19091 | SC | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.