1477612414 NPI number — LARRY W ANDERSON, DO, LLC

Table of content: (NPI 1477612414)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477612414 NPI number — LARRY W ANDERSON, DO, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LARRY W ANDERSON, DO, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477612414
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/27/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6002 HIGHWAY 53 E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAWSONVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30534-6227
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-265-1335
Provider Business Mailing Address Fax Number:
706-265-2296

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6002 HIGHWAY 53 E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAWSONVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30534-6227
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-265-1335
Provider Business Practice Location Address Fax Number:
706-265-2296
Provider Enumeration Date:
12/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
LARRY
Authorized Official Middle Name:
W
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
706-265-1335

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  020648 , 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: GRP7339 . This is a "MEDICARE LEGACY" identifier . This identifiers is of the category "OTHER".
  • Identifier: DG1560 . This is a "RAILROAD MEDICARE GRP #" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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