Provider Demographics
NPI:1427150796
Name:ANDERSON, KEVIN C (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:C
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:574-237-6069
Practice Address - Street 1:100 NAVARRE PL STE 4440
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1171
Practice Address - Country:US
Practice Address - Phone:574-647-5300
Practice Address - Fax:574-647-5305
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01079147A207X00000X, 207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300006370Medicaid
IN231860006OtherMEDICARE PTAN
IN169380066OtherMEDICARE PTAN
IN247000022OtherMEDICARE PTAN
IN300006370Medicaid
IN565800033OtherMEDICARE PTAN
IN233530015OtherMEDICARE PTAN