=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437467354
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDERSEN IRVIN GRIGG DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2010
-----------------------------------------------------
Last Update Date | 09/14/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | UNIVERSITY OF KENTUCKY AND AFFILIATES 800 ROSE ST.
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40536-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-332-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 791 TYRUS CT
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40515-5541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-523-5274
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | R1686
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------