Basic Information
Provider Information | |||||||||
NPI: | 1700850195 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ANDERSEN | ||||||||
FirstName: | WILLIAM | ||||||||
MiddleName: | KRISTIAN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2000 PERIMETER PARK DR STE 200 | ||||||||
Address2: |   | ||||||||
City: | MORRISVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 275608442 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9194674992 | ||||||||
FaxNumber: | 9194819607 | ||||||||
Practice Location | |||||||||
Address1: | 1120 SE CARY PKWY | ||||||||
Address2: | SUITE 100 | ||||||||
City: | CARY | ||||||||
State: | NC | ||||||||
PostalCode: | 275187413 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9194674992 | ||||||||
FaxNumber: | 9194819607 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/14/2006 | ||||||||
LastUpdateDate: | 09/13/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/13/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | 9600842 | NC | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
ID | Type | State | Issuer | Description | NNF119L103 | 01 | NC | MEDICARE | OTHER | 11124 | 01 | NC | BCBS | OTHER | 1700850195 | 05 | NC |   | MEDICAID | 2111516 | 01 | NC | UNITED HEALTHCARE | OTHER | 5406276 | 01 | NC | AETNA PPO | OTHER | 2076472 | 01 | NC | FIRST HEALTH | OTHER | 2350709 | 01 | NC | AETNA HMO | OTHER |