Healthcare Provider Details

I. General information

NPI: 1942405923
Provider Name (Legal Business Name): KATHY M ANDERSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2007
Last Update Date: 01/06/2025
Certification Date: 05/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 BURNT BOAT DR. SUITE B
BISMARCK ND
58503
US

IV. Provider business mailing address

1930 BURNT BOAT DR. SUITE B
BISMARCK ND
58503
US

V. Phone/Fax

Practice location:
  • Phone: 701-490-9596
  • Fax:
Mailing address:
  • Phone: 701-490-9596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number11368
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1460870
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: