1619945615 NPI number — DR. BRIAN N. ANDERSON MD

Table of content: SAMANTHA NICOLE SPENCER (NPI 1649075540)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619945615 NPI number — DR. BRIAN N. ANDERSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
BRIAN
Provider Middle Name:
N.
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:
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:
1619945615
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/11/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
836 E. 65TH STREET
Provider Second Line Business Mailing Address:
SUITE 20
Provider Business Mailing Address City Name:
SAVANNAH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-819-7878
Provider Business Mailing Address Fax Number:
912-819-3555

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 OAK FOREST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
BLUFFTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-815-3006
Provider Business Practice Location Address Fax Number:
843-815-3737
Provider Enumeration Date:
03/08/2006

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: 207QS0010X , with the licence number:  16696 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QS0010X , with the licence number: SC16696 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 166965 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 571073118 . This is a "TAX ID" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 080160922 . This is a "MEDICARE RR" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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