1073685418 NPI number — DR. MICHAEL GEORGE ANDERSON MD

Table of content: DR. MICHAEL GEORGE ANDERSON MD (NPI 1073685418)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073685418 NPI number — DR. MICHAEL GEORGE ANDERSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
MICHAEL
Provider Middle Name:
GEORGE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ANDERSON
Provider Other First Name:
MICHAEL
Provider Other Middle Name:
GEORGE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD, PC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1073685418
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
391 EAST MAIN STREET
Provider Second Line Business Mailing Address:
HISTORIC HAWKINS BUILDING
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30114-2712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-720-6963
Provider Business Mailing Address Fax Number:
770-720-6965

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
391 EAST MAIN STREET
Provider Second Line Business Practice Location Address:
HISTORIC HAWKINS BUILDING
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30114-2712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-720-6963
Provider Business Practice Location Address Fax Number:
770-720-6965
Provider Enumeration Date:
11/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  054532 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 268736326A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 629697125A . This is a "MEDICAID PAYOR ID# EMPLOYER NORTHSIDE CHILDREN'S PEDIATRICS CTR, NPI# 1396945515" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1609087972 . This is a "AUTHORIZED CONTACT REPRESENTATIVE: STEPHANIE H. ANDERSON, NPI#" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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