Provider Demographics
NPI:1215938782
Name:ANDERSON, LIBBY S (MD)
Entity type:Individual
Prefix:
First Name:LIBBY
Middle Name:S
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:2800 SPRING ARBOR RD STE 102
Mailing Address - Street 2:PO BOX 905
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-3895
Mailing Address - Country:US
Mailing Address - Phone:517-783-2612
Mailing Address - Fax:517-783-5991
Practice Address - Street 1:205 N EAST AVE
Practice Address - Street 2:IMAGING DEPARTMENT
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1753
Practice Address - Country:US
Practice Address - Phone:517-783-2612
Practice Address - Fax:517-783-6095
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2017-01-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI43010438162085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1434678Medicaid
MI3003800401OtherBCBS OF MICHIGAN
300020171OtherRAILROAD MEDICARE
MI4301043816OtherSTATE OF MICHIGAN MEDICAL LICENSE
B48819Medicare UPIN