Healthcare Provider Details

I. General information

NPI: 1669884433
Provider Name (Legal Business Name): IAN JACOB ANDERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2014
Last Update Date: 05/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22101 MOROSS RD # CCB-SB
DETROIT MI
48236-2148
US

IV. Provider business mailing address

22101 MOROSS RD # CCB-SB
DETROIT MI
48236-2148
US

V. Phone/Fax

Practice location:
  • Phone: 313-343-3520
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number4301101517
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: