Basic Information
| Provider Information | |||||||||
| NPI: | 1043539836 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | MARISSA | ||||||||
| MiddleName: | LEA | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 95 COLLIER RD NW STE 4025 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303091750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4045745820 | ||||||||
| FaxNumber: | 4045745821 | ||||||||
| Practice Location | |||||||||
| Address1: | 95 COLLIER RD NW STE 4025 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303091750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4045745820 | ||||||||
| FaxNumber: | 4045745820 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2010 | ||||||||
| LastUpdateDate: | 09/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 262804 | MA | N | Allopathic & Osteopathic Physicians | Surgery | 390200000X | BP10038035 | TX | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208C00000X | 83360 | GA | Y | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
No ID Information.