Healthcare Provider Details

I. General information

NPI: 1790245611
Provider Name (Legal Business Name): KEITH ANDERSON JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 W FOREST AVE FL 4
JACKSON TN
38301-3937
US

IV. Provider business mailing address

257 BANCORP SOUTH PKWY
JACKSON TN
38305-7582
US

V. Phone/Fax

Practice location:
  • Phone: 731-541-2250
  • Fax:
Mailing address:
  • Phone: 731-542-2250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number77727
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: