Basic Information
| Provider Information | |||||||||
| NPI: | 1164510491 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THAGGARD | ||||||||
| FirstName: | ANSON | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 NORTH STATE STREET | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019842538 | ||||||||
| FaxNumber: | 6018151854 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 NORTH STATE STREET | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019842538 | ||||||||
| FaxNumber: | 6018151854 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 12/03/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 13216 | MS | N | Allopathic & Osteopathic Physicians | Family Medicine | 2085R0202X | 13216 | MS | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085N0904X | 13216 | MS | N | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology |
ID Information
| ID | Type | State | Issuer | Description | POO634041 | 01 | RAILROAD MEDICARE | OTHER | 00203599 | 05 | MS | MEDICAID | 179025 | 05 | AL | MEDICAID | P01202306 | 01 | MS | RAILROAD MEDICARE PTAN | OTHER |