Basic Information
| Provider Information | |||||||||
| NPI: | 1093033029 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSEN | ||||||||
| FirstName: | DESIRE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HURST | ||||||||
| OtherFirstName: | DESIRE | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1234 NAPIER AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490852112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699838500 | ||||||||
| FaxNumber: | 2699854535 | ||||||||
| Practice Location | |||||||||
| Address1: | 1234 NAPIER AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490852112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699838500 | ||||||||
| FaxNumber: | 2699854535 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2010 | ||||||||
| LastUpdateDate: | 03/03/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 4301103974 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1093033029 | 05 | MI | MEDICAID |