Provider Demographics
NPI:1609124080
Name:ANDERSON, KEVIN MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:MICHAEL
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 OKATIE CTR BLVD
Mailing Address - Street 2:
Mailing Address - City:OKATIE
Mailing Address - State:SC
Mailing Address - Zip Code:29909-7529
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4 OKATIE CTR BLVD
Practice Address - Street 2:
Practice Address - City:OKATIE
Practice Address - State:SC
Practice Address - Zip Code:29909-7529
Practice Address - Country:US
Practice Address - Phone:843-706-3206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-16
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC82114208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program