Basic Information
| Provider Information | |||||||||
| NPI: | 1770096745 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | THOR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7901 ANGLING RD | ||||||||
| Address2: | |||||||||
| City: | PORTAGE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490240714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693248600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5973 BEATRICE DR | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490099583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2692867110 | ||||||||
| FaxNumber: | 2692867111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2017 | ||||||||
| LastUpdateDate: | 10/02/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4704257204 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QA0505X | 4704257204 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine | 363L00000X | 4704257204 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 4704257204 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.