Provider Demographics
NPI:1285618975
Name:ANDERSON, KEITH CHARLES (DO)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:CHARLES
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4799
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35815-4799
Mailing Address - Country:US
Mailing Address - Phone:256-539-4545
Mailing Address - Fax:256-539-4990
Practice Address - Street 1:201 GOVERNORS DRIVE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-5123
Practice Address - Country:US
Practice Address - Phone:256-533-8100
Practice Address - Fax:256-533-8101
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-06
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO250208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL83822OtherBLUE CROSS
180012766OtherMC RR
8045502OtherCIGNA
167578000OtherUS DEPT OF LABOR
AL000083822Medicaid
TN4046275Medicaid
1451629OtherUNITED MINE WORKERS
167578000OtherUS DEPT OF LABOR
AL000083822Medicare ID - Type Unspecified