Healthcare Provider Details

I. General information

NPI: 1801854021
Provider Name (Legal Business Name): KIRK R ANDERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 01/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 RIVER BEND LN
PROVO UT
84604-5625
US

IV. Provider business mailing address

1055 N 500 W
PROVO UT
84604-3305
US

V. Phone/Fax

Practice location:
  • Phone: 801-226-8880
  • Fax:
Mailing address:
  • Phone: 801-429-8000
  • Fax: 801-429-8150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number1621571205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: