MEDICARE: JACK D ANDERSON DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	03464	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245527969
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK D ANDERSON DO

Provider Business Mailing Address
First Line	:	PO BOX 1080
Second Line	:
City	:	BURKESVILLE
State	:	KY
Zip	:	42717-1080
Country	:	US
Telephone Number	:	270-864-1472
Fax Number	:	270-864-1693

Provider Business Practice Location Address
First Line	:	1515 EDMONTON RD
Second Line	:
City	:	TOMPKINSVILLE
State	:	KY
Zip	:	42167-9402
Country	:	US
Telephone Number	:	270-487-9272
Fax Number	:	270-487-6242

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/01/2011
Last Update Date	:	06/10/2014

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Directions to “ JACK D ANDERSON DO” Practice Location

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