Healthcare Provider Details

I. General information

NPI: 1407506413
Provider Name (Legal Business Name): JESSE STEPHEN ANDERSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2022
Last Update Date: 06/13/2026
Certification Date: 06/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

274 E CHICAGO ST
COLDWATER MI
49036-2041
US

IV. Provider business mailing address

36475 FIVE MILE RD
LIVONIA MI
48154-1971
US

V. Phone/Fax

Practice location:
  • Phone: 517-279-5400
  • Fax:
Mailing address:
  • Phone: 734-655-4800
  • Fax: 734-655-2911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4301515312
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: