MEDICARE: KEVIN MICHAEL ANDERSON MD

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	390200000X	Student in an Organized Health Care Education/Training Program
2	208000000X	Pediatrics Physician	82114	SC

General Provider Information

NPI Number	:	1609124080
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN MICHAEL ANDERSON MD

Provider Business Mailing Address
First Line	:	4 OKATIE CTR BLVD
Second Line	:
City	:	OKATIE
State	:	SC
Zip	:	29909-7529
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4 OKATIE CTR BLVD
Second Line	:
City	:	OKATIE
State	:	SC
Zip	:	29909-7529
Country	:	US
Telephone Number	:	843-706-3206
Fax Number	:

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

Provider Enumeration Date	:	08/16/2012
Last Update Date	:	08/20/2019

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