Provider Demographics
NPI:1902835309
Name:ANDERSEN, LARS P JR (DO)
Entity Type:Individual
Prefix:DR
First Name:LARS
Middle Name:P
Last Name:ANDERSEN
Suffix:JR
Gender:M
Credentials:DO
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Mailing Address - Street 1:1005 S US HIGHWAY 27
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAINT JOHNS
Mailing Address - State:MI
Mailing Address - Zip Code:48879-2423
Mailing Address - Country:US
Mailing Address - Phone:989-224-3000
Mailing Address - Fax:989-224-1424
Practice Address - Street 1:1005 S US HIGHWAY 27
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT JOHNS
Practice Address - State:MI
Practice Address - Zip Code:48879-2423
Practice Address - Country:US
Practice Address - Phone:989-224-3000
Practice Address - Fax:989-224-1424
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2016-08-11
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Provider Licenses
StateLicense IDTaxonomies
MI5101006728207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3026510Medicaid
MICE4044OtherRAILROAD MEDICARE B
MIOA96001003Medicare PIN
MI3026510Medicaid