Healthcare Provider Details

I. General information

NPI: 1356720387
Provider Name (Legal Business Name): KEVIN ANDERSON M.D, PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2015
Last Update Date: 06/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HAMPTON RD UNIT 208
EXETER NH
03833-4849
US

IV. Provider business mailing address

330 BROOKLINE AVE DEPARTMENT OF PATHOLOGY
BOSTON MA
02215-5400
US

V. Phone/Fax

Practice location:
  • Phone: 866-484-3522
  • Fax: 603-778-1602
Mailing address:
  • Phone: 617-667-4344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number269567
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number256001
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number18713
License Number StateNH
# 4
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberMD22122
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: