Basic Information
| Provider Information | |||||||||
| NPI: | 1316916182 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 N STEPHANIE ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029523350 | ||||||||
| FaxNumber: | 7029523365 | ||||||||
| Practice Location | |||||||||
| Address1: | 3730 S EASTERN AVE | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029523400 | ||||||||
| FaxNumber: | 7029523460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2006 | ||||||||
| LastUpdateDate: | 07/18/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 10398 | NV | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | XPY201559 | 05 | CA | MEDICAID | 2018819 | 05 | NV | MEDICAID |