Basic Information
| Provider Information | |||||||||
| NPI: | 1083611057 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STANTON | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | C | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 497 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720060497 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703472534 | ||||||||
| FaxNumber: | 8703473492 | ||||||||
| Practice Location | |||||||||
| Address1: | 4100 HARRISON ST | ||||||||
| Address2: | |||||||||
| City: | BATESVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 725019419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703070001 | ||||||||
| FaxNumber: | 8703070395 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2005 | ||||||||
| LastUpdateDate: | 11/01/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | E-1905 | AR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080189277 | 01 | RAILROAD MEDICARE | OTHER | 138378001 | 05 | AR | MEDICAID |