Healthcare Provider Details

I. General information

NPI: 1700874294
Provider Name (Legal Business Name): JOHN G ANDERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 01/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 LEFFINGWELL AVE NE STE 100
GRAND RAPIDS MI
49525
US

IV. Provider business mailing address

1111 LEFFINGWELL AVE NE STE 100
GRAND RAPIDS MI
49525
US

V. Phone/Fax

Practice location:
  • Phone: 616-459-7101
  • Fax: 616-464-6170
Mailing address:
  • Phone: 616-459-7101
  • Fax: 616-464-6170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number4301070607
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: