Provider Demographics
NPI:1528331642
Name:ANDERSON ORAL AND MAXILLOFACIAL SURGERY, P.S.C
Entity type:Organization
Organization Name:ANDERSON ORAL AND MAXILLOFACIAL SURGERY, P.S.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL AND MAXILLOFACIAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:606-878-6126
Mailing Address - Street 1:1675 S MAIN ST
Mailing Address - Street 2:LAUREL MEDICAL CENTER, LOWER LEVEL
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741-2050
Mailing Address - Country:US
Mailing Address - Phone:606-878-6126
Mailing Address - Fax:606-878-0840
Practice Address - Street 1:1675 S MAIN ST
Practice Address - Street 2:LAUREL MEDICAL CENTER, LOWER LEVEL
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-2050
Practice Address - Country:US
Practice Address - Phone:606-878-6126
Practice Address - Fax:606-878-0840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-21
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6656261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64066566Medicaid
KY1256606Medicare PIN
KY64066566Medicaid