Provider Demographics
NPI:1215964747
Name:MICHAEL B ANDERSON, MD PC
Entity type:Organization
Organization Name:MICHAEL B ANDERSON, MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-628-9393
Mailing Address - Street 1:1490 E FOREMASTER DR
Mailing Address - Street 2:# 150
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-4488
Mailing Address - Country:US
Mailing Address - Phone:435-628-9393
Mailing Address - Fax:
Practice Address - Street 1:1490 E FOREMASTER DR
Practice Address - Street 2:# 150
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-4488
Practice Address - Country:US
Practice Address - Phone:435-628-9393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1722171205207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528849385003Medicaid
UT528849385003Medicaid